UC-NRLF 


SB    2fl    IDS 


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Division 

Range 

Shelf : 

Received 


18 


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University  of  California 


1879. 


9. 


I 


tit. 


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LECTURES 


ON 


PRACTICAL  SURGERY, 


BY 


H.  H.   TOLAND,  M.D., 

PROFESSOR    OP   THE    PRINCIPLES    AND    PRACTICE    OP    SURGERY    AND    CLINICAL 

SURGERY    IN    THE    MEDICAL    DEPARTMENT    OP    THE 

UNIVERSITY    OP    CALIFORNIA. 


WITH 


NUMEROUS   ILLUSTRATIONS. 
I;  I  P>  R  A  H  \ 

UNIVERSITY  OF 

CALIFORNIA. 


PHILADELPHIA: 
LINDSAY    &    BLAKISTON. 

1877. 


Entered  according  to  Act  of  Congress,  in  the  year  1877, 

BY  H.  H.  TOLAND,  M.D., 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


SHERMAN  &  CO.,  PRINTERS, 
PHILADELPHIA. 


AFFECTIONATELY 


TO    THE    STUDENTS 

OF 

THE    MEDICAL    DEPARTMENT   OF    THE  UNIVERSITY 
OF   CALIFORNIA. 


PREFACE. 


BEFORE  the  Toland  College  was  transferred  by  the  Trus- 
tees to  the  Regents  of  the  University  of  California,  and 
thereby  became  the  medical  department  of  that  Institution, 
the  students  requested  me  to  write  a  text-book ;  I  told  them 
that  my  engagements  were  so  numerous  that  I  could  not 
find  time  to  write  a  book  with  the  scientific  accuracy  of  some 
that  had  been  published,  but  that  if  they  were  willing,  'I 
would  talk  a  book  that  would  contain  the  principles  of 
Surgery,  with  illustrations  from  my  own  experience. 

That  proposition  being  agreeable,  Mr.  Marsh,  one  of  the 
best  stenographers  of  this  city,  was  employed  to  take  down 
my  oral  lectures  before  the  class.  These  lectures  were 
delivered  extemporaneously,  and  should  they  contain  any- 
thing not  original,  without  an  acknowledgment  or  quo- 
tation-marks, I  wish  it  to  be  distinctly  understood  that 
the  omission  was  not  intentional. 

H.  H.  TOLAND. 

SAN  FRANCISCO,  CAL., 
September  1st,  1877. 


TABLE  OF  CONTENTS. 


LECTURE  I. 

General  Considerations.     Consequences  of  Operations ;    Anaesthetics  ;    Haemor- 
rhage;  After-treatment ;  Congestion,       17 


LECTURE  II. 

Sympathy  ;  Irritation  ;  Inflammation  ;  Symptoms  ;  Cause  ;  Nature,    .         .     26 

LECTURE  III. 

Kemedies  for  Inflammation  ;  Bloodletting  ;  Cathartics  ;  Diaphoretics  5  Diuretics  ; 
Anodynes,  ............  38 

LECTURE  IV. 

Depressants  ;  Regimen  ;  Local  Bleeding;  Fomentations  ;  Poultices }  Stimulants  ; 
Destructives  ;  Counter-irritants  ;  Vesicants,  ......  48 

LECTURE  V. 

Chronic  Inflammation  ;  Treatment ;  Terminations  of  Inflammation  ;  Delites- 
cence ;  Resolution  ;  Mortification  ;  Senile  Gangrene ;  Results  of  Inflamma- 
tion ;  Effusion  of  Serum  ;  Lymphization,  ......  57 

LECTURE  VI. 

Lymphization  (continued);  Suppuration;  Multiple  Abscesses ;  Scrofulous  Ab- 
scesses,   73 

LECTURE  VII. 

Results  of  Inflammation  (continued);  Haemorrhage.  Absorption.  Ulceration  ; 
Varieties  ;  Treatment.  Ramollissement  or  Softening.  Induration.  Trans- 
formation ;  Cellular ;  Fibrous ;  Calcareous ;  Fatty.  Atrophy.  Contrac- 
tion, 83 


Vlll  TABLE    OF    CONTENTS. 


LECTURE  VIII. 

Congenital  Malformations;  Fissures;  Hypospadias ;  Enlargement  of  Fontanelles. 
Absence  of  Structures  ;  Harelip  ;  Fissure  of  Palate.  Wryneck.  Club-foot; 
Varieties  ;  Treatment ;  Flatfoot.  Disease  of  the  Knee.  Podelcoma.  Podo- 
dynia, 98 

LECTURE  IX. 

Congenital  Malformations  (continued)  ;  Occlusion  of  Rectum.  Nsevus.  Tumors  ; 
Vascular  Sarcoma;  Warts  and  Polypi;  Adipose  Tumors;  Encysted 
Tumors  or  Cystic  Sarcomata ;  Wens;  Neuromata.  Hydatids,  .  .  112 


LECTURE  X. 

Semi-malignant  Tumors  ;  Fibrous  ;  Recurring  Fibrous  ;  Enchondromatous  ; 
Keloid  ;  Epitheliomatous.  Malignant  Tumors;  Colloid;  Encephaloid  ; 
Scirrhous ;  Melanotic, 122 


LECTURE  XI. 

Scrofula.     Tubercle, 141 

LECTURE  XII. 

Structure  of  Arteries ;  Fatty  Degeneration.  Wounds  of  Arteries  ;  Arrest  of 
Haemorrhage;  Natural;  Artificial.  Venous  Haemorrhage, .  .  .  152 

LECTURE  XIII. 

Aneurism;  Fusiform;  Sacculated  ;  Dissecting;  Symptoms  ;  Treatment.  Dila- 
tation of  Veins,  ...........  161 

LECTURE  XIV. 

Varicose  Aneurism.     Operations  for  Aneurism  ;  Ligation  of  Arteries,       .     174 

LECTURE  XV. 

Hernia.  Anatomy  of  Abdomen  ;  Causes  of  Hernia  ;  Symptoms  ;  Strangulation  ; 
Incarceration;  Operation;  Femoral  Hernia ;  Umbilical;  Ventral;  After- 
treatment  of  Operation,  ..........  186 

LECTURE  XVI. 

Stone  in  the  Bladder  ;  Causes  ;  Varieties  ;  Treatment ;  Lithotrity  ;  Lithot- 
omy,   198 


TABLE    OF    CONTENTS.  IX 


LECTURE  XVII. 

Stone  in  the  Bladder  (continued)  ;  Collapse;  Haemorrhage;  Infiltration  of 
Urine;  Inflammation.  Stone  in  the  Female  Bladder.  Retention  of  Urine; 
Incontinence  of  Urine.  Gonorrhoea, 209 


LECTURE  XVIII. 

Gonorrhoaa  (continued) ;  Treatment.     Stricture;    Treatment  of  Stricture.     Ca- 
tarrh of  the  Bladder.     Disease  of  the  Prostate, 218 


LECTURE  XIX. 

Wounds  ;  Bruises  or  Contusions  ;  Incised  Wounds  ;  Punctured  Wounds  ;  Con- 
tused Wounds  ;  Gunshot  Wounds, 231 


LECTURE  XX. 

Gunshot  Wounds  (continued).    Effects  of  Heat  and  Cold  ;  Burns,       .         .     402 

LECTURE  XXI. 

Poisons.  Animal  Poisons;  Rattlesnake  Bites;  Hydrophobia.  Dissecting 
Wounds.  Amputations;  Circular  and  Flap  Methods  ;  Haemorrhage;  Puru- 
lent Absorption  ;  Excessive  Suppuration  ;  Exfoliation  of  Bone,  .  .  249 

LECTURE  XXII. 

Amputations  (continued) ;  Special  Amputations, 260 

LECTURE  XXIII. 

Fractures;  Symptoms;  Mode  of  Union;  Treatment.     Special  Fractures, .     269' 

LECTURE  XXIV. 

Fractures  (continued), 278' 

LECTURE  XXV. 

Fractures  (continued), 286- 

LECTURE  XXVI. 

Dislocations,          ............     296* 

1* 


X  TABLE    OF    CONTENTS. 

LECTURE  XXVII. 

Dislocations  (continued).     False  Joints,        ....  .  302 

LECTURE  XXVIII. 

Diseases  of  the  Bones  ;  Inflammation  ;  Reproduction  of  Bones  ;  Periostitis  ; 
Necrosis;  Caries.  Subporiosteal  Resections.  Abscess.  Exostosis.  Osteo- 
sarooma ;  Fibrous;  Medullary.  Rickets.  Mollities  Ossium,  .  .  309 

LECTURE  XXIX. 

Disease  of  the  Spine  ;  Sprains;  Inflammation  of  Joints,     ....     319 

LECTURE  XXX. 

Incised  Wounds  of  Joints.  Movable  Cartilages.  White  Swelling.  Morbus 
Coxarius,  .*..........  327 

LECTURE  XXXI. 

^Hysterical  Affections  of  Joints.  Injuries  of  Muscles.  Injuries  of  Tendons. 
Bursre.  Wounds -of  the  Throat ;  Tracheotomy,  .  .  .  .  .337 

LECTURE  XXXII. 

Wounds  of  the  Chest.     Goitre.     Emphysema.     Pneumothorax,          .         .     346 

LECTURE  XXXIII. 

Wounds  of  the  Abdomen.  Tapping.  Foreign  Bodies  in  the  Nose;  Epistaxis. 
Foreign  Bodies  in  the  Ear, 365 

LECTURE  XXXIV. 

Polypus  of  the  Nose.  Ulceration  of  the  Septum.  Lupus.  Hypertrophy  of  the 
Nose.  Inflammation  of  the  Ear.  Diseases  of  the  Jaws.  Ulceration  of  the 
Mouth.  Hypertrophy  of  the  Tongue.  Tongue-tie.  Inflammation  of  the 
Tonsils.  The  Teeth,  . .  .  3G3 

LECTURE  XXXV. 

Concussion  of  the  Brain.  Compression  of  the  Brain.  Paralysis.  Depressed 
Fracture  of  Skull.  Tumors  of  the  Brain.  Spina  Bifida.  Injuries  of 
Nerves, .  .  .  .  373 


TABLE    OF    CONTENTS.  XI 

LECTURE  XXXVI. 

Diseases  of  the  Breast, .382 

LECTURE  XXXVII. 

Diseases  of  the  Uterus  and  other  Female  Genital  Organs,   ....     388 

LECTURE  XXXVIII. 

Ovarian  Tumors  ;  Ovariotomy.     Vesico-vaginal  Fistula,  .  ...     398 

LECTURE  XXXIX. 

Diseases  of  the  Eye.  Conjunctivitis.  Strumous  Ophthalmia.  Purulent  Ophthal- 
mia. Gonorrheal  Ophthalmia,  ........  406 

LECTURE  XL. 

Diseases  of  the  Eye  (continued).  Staphyloma.  Iritis.  Dropsy  of>the  Eye. 
Amaurosis.  Cataract.  Entropium.  Ectropium.  Encanthus.  Epithelioma. 
Fistula  Lachrymalis.  Strabismus,  . 413 

LECTURE  XLI. 

Spermatorrhoea.     Impotence,      ,         .         .         .         .          ....     424 

LECTURE  XLII. 

Skin-grafting.     Epithelioma.     Deformities  of  the  Nose.     Bunions,    .         .     429 

LECTURE  XLIII. 

Syphilis  and  its  Treatment.  Origin  of  the  Disease^  History.  Chancres,  Primi- 
tive and  Consecutive  ;  Stationary,  Phagedenic,  and  Serpiginous.  Treat- 
ment,   439 

LECTURE  XLIV. 

Constitutional  Treatment  of  Primary  Syphilis.  Different  forms  in  which  Mer- 
cury may  be  administered.  Iodide  of  Potassium,  ....  447 

LECTURE  XLV. 

Bubo ;   Varieties  ;  Local  Treatment.     Cases, 455 


Xll  TABLE    OP    CONTENTS. 


LECTURE  XLVI. 

Secondary  Syphilis.  Origin.  Preventability.  Affections  of  the  Mucous  Mem- 
branes. Erosion.  Secondary  Chancre.  Diagnosis.  Cases.  Affections  of 
the  Nose  and  of  the  Throat.  Treatment, 462 


LECTURE  XLVII. 

Secondary  Syphilis  (continued).     Syphilitic  Exanthema.     Syphilides.     Incuba- 
tion.    Lagneau's  Classification,      ........     471 


LECTURE  XLVITI. 

Secondary  Syphilis  (continued).  Alopecia.  Onychia.  Syphilitic  Rheumatism 
Syphilitic  Sarcocele.  Gummy  Tumors.  Conjunctivitis.  Iritis,.  .  481 

LECTURE  XLIX. 

Treatment  of  Secondary  and  Tertiary  Syphilis  ;  Ptisanes  ;  Gold  ;  Platinum  ; 
Arsenic  ;  Iron  ;  Mercurial  Fumigations.  Periostitis.  Ostitis.  Exostosis. 
Caries.  Necrosis, 489 


APPENDIX. 

Operation  for  Deformity  of  Nose  by  Injury.  Encephaloid  Tumor  of  Bone. 
Excision  of  Elbow.  Injury  of  Foot;  Excision  of  Bones.  Examination 
of  the  Rectum, 501 


LIBRA  R  1 

UNIVERSITY  OF 

CALIFORNIA. 


LECTURES  ON  PRACTICAL  SURGERY, 


LECTURE   I. 

THE  science  of  medicine  embraces  everything  which  has  a  tendency 
to  preserve  health  or  cure  disease.  For  convenience  it  has  been 
divided  into  medicine  and  surgery.  The  former  includes  remedies 
for  all  internal  and  functional  derangements ;  the  latter,  remedies  for 
organic  and  external  lesions,  which  require  either  local  applications 
or  manual  interference  for  relief. 

So  long  as  the  surgeon  occupied  a  less  honorable  position,  and  was 
only  an  assistant  to  the  physician,  this  division  was  both  convenient 
and  necessary,  but  now  in  consequence  of  the  great  progress  made  in 
every  department  of  surgery  during  the  last  half  century,  it  becomes 
impossible  to  separate  it  entirely  from  medicine,  and  he  who  expects 
to  succeed  as  a  surgeon,  without  having  a  correct  knowledge  of  every 
branch  of  the  profession,  will  find  that  he  is  unable  to  compete  with 
him  who  is  not  only  familiar  with  the  symptoms  and  pathology  of 
diseases,  but  also  understands  perfectly  the  effect  of  remedies  ad- 
ministered for  their  relief,  and  can  appreciate  their  relative  value  in 
the  different  stages  of  the  same  affection. 

The  word  surgery  is  derived  from  two  Greek  words,  /^/>,  the  hand, 
and  epYuv,  work,  because  the  ancients  supposed  that  manual  dexterity 
was  all  that  the  surgeon  required,  as  they  were  ignorant  alike  of  the 
anatomy  and  diseases  of  the  human  body. 

The  surgeon  during  the  last  half  century  has  not  been  considered 
inferior  to  the  physician.  He  must  be  his  equal  in  medicine  to  be- 
come eminent,  and  besides  possessing  a  knowledge  of  the  exact  science 
of  surgery  with,  to  use  the  language  of  Celsus,  "A  hand  steady,  ex- 
pert, and  never  tremulous,  clear  sight,  and  an  intrepid  mind,"  I 
will  add,  he  should  combine  caution  with  mechanical  genius. 

2 


18  LECTURES  ON  PRACTICAL  SURGERY. 

For  convenience  surgery  may  be  divided  into  theoretical  and 
operative  surgery. 

The  first  includes  the  consideration  of  all  surgical  diseases,  as  well 
as  the  treatment  of  those  which  can  be  relieved  without  a  surgical 
operation.  They  will  constitute  a  very  important  part  of  this  course 
of  lectures,  and  if  I  have  the  ability  to  present  them  properly,  much 
the  most  useful  to  the  class. 

Operative  Surgery  is  divided  into  Minor  and  Major  Surgery.  The 
former  includes  the  application  of  bandages,  the  dressing  of  wounds, 
and,  indeed,  all  the  small  but  exceedingly  important  details  necessary 
in  practice.  They  require  less  nerve,  less  skill,  and  involve  less  re- 
sponsibility, but  to  the  general  practitioner  are  much  more  important 
than  great,  or,  as  they  are  called,  capital  operations,  which  Major 
Surgery  includes.  It  is  divided  into  Military  and  Conservative  or 
Plastic  Surgery. 

The  former  embraces  the  operations  that  are  performed  either  on 
the  battle-field,  or  after  the  wounded  have  been  removed,  as  well  as 
the  treatment  of  gunshot  wounds  generally. 

The  latter  has  within  a  few  years  made  more  rapid  progress  than 
any  branch  of  the  profession,  and  I  think  it  can,  to  the  honor  of 
American  surgeons,  be  said  that  they  have  contributed  more  than 
those  of  any  other  country  to  the  development  of  important  improve- 
ments in  operative  surgery.  When  I  have  saved  a  condemned  limb, 
restored  a  lost  part,  or  have  otherwise  prevented  or  removed  de- 
formity and  mutilation,  I  feel  my  pride  for  the  profession  increase, 
and  a  consciousness  that  I  have  been  compensated  for  the  toil  and 
anxiety  all  must  encounter  to  obtain  even  a  respectable  position  in 
the  profession.  The  surgeon  who  avails  himself  for  the  benefit  of 
his  patient  of  everything  which  both  science  and  art  contribute, 
should  not  be  confounded  with  the  knife's-man,  whose  highest  am- 
bition is  to  obtain  notoriety  by  the  unnecessary  and  consequently 
reckless  waste  of  human  blood. 

In  order  to  prevent  repetition  during  the  remainder  of  this  course 
of  lectures,  there  are  some  general  considerations  for  the  management 
of  surgical  cases  to  which  I  now  propose  to  direct  your  attention. 

If  it  be  possible  to  arrest  a  disease  and  restore  a  patient  to  health 
by  other  means,  never  perform  a  surgical  operation.  When  the 
lymphatic  ganglions  are  enlarged  in  scrofulous  subjects,  those  who 
rely  exclusively  upon  the  knife  frequently  remove  them,  and  in  a 


LECTURE  I. — THE  SCIENCE  OF  SURGERY.        19 

short  time  the  difficulty  reappears,  and  will  continue  to  increase  until 
its  progress  is  arrested  by  a  judicious  course  of  medical  treatment. 

The  most  serious  consequences  occasionally  result  from  the  slightest 
operation.  When  a  constitutional  derangement  exists  which  the 
most  experienced  may  fail  to  detect,  death  may  result  from  cutting  a 
corn,  or  the  removal  of  a  simple  encysted  or  adipose  tumor.  Such 
a  casualty,  besides  the  sacrifice  of  a  human  life,  always  injures  the 
reputation  of  a  young  surgeon. 

For  the  same  reason  in  malignant  diseases,  and  particularly  when 
the  evidences  of  a  cancerous  diathesis  exist,  avoid  an  operation  if 
possible.  The  disease  in  such  cases  almost  always  returns  if  re- 
moved, and  it  is  very  doubtful  whether  the  life  of  a  patient  can  even 
be  prolonged  by  any  course  of  treatment  that  can  be  adopted.  Sur- 
geons of  established  reputation  may  not  adhere  rigidly  to  this  course, 
yet  they  should,  and  in  future  I  have  resolved  never  again  to  use 
the  knife  when  it  affords  no  chance  even  to  arrest  the  ravages  of 
disease.  In  curable  cases,  even  when  the  life  of  a  patient  is  not  in 
imminent  danger,  never  persuade  any  one  to  submit  to  an  opera- 
tion, except  in  strangulated  hernia,  or  aneurism  of  the  arteries  of  the 
extremities,  or  stone  in  the  bladder;  then  it  is  perfectly  justifiable, 
with  the  consent  of  the  friends,  to  administer  an  anaesthetic  and  per- 
form the  necessary  operation.  In  all  other  cases,  put  the  question,  as 
Dupuytren  always  did,  with  a  knife  in  his  hand,  "  Will  you  be  oper- 
ated upon  or  not?"  and  then  if  not  successful  you  will  have  nothing 
to  regret,  or  anything  with  which  you  can  reproach  yourself. 

After  a  patient  has  consented,  and  when  placed  upon  the  table,  if 
an  extraordinary  dread  of  the  consequences  be  apparent,  I  would 
advise  you  by  all  means  to  defer  the  operation  until  the  mental  con- 
dition improves,  and  if  more  favorable  circumstances  do  not  present, 
it  should  be  indefinitely  postponed.  If  that  course  is  not  adopted  in 
such  cases,  the  system  may  never  react,  stimulants  will  produce  no 
effect,  and  the  patient  will  sink  as  rapidly  from  a  simple  wound  as 
from  the  shock  resulting  from  an  extensive  burn  or  the  crushing  of 
one  of  the  lower  extremities. 

Dupuytren  removed  a  small  encysted  tumor  from  the  back  of  an 
apparently  healthy  young  man.  He  consented  to  the  operation,  but 
had  a  presentiment  that  it  would  prove  fatal.  He  was  only  a  few 
minutes  on  the  table,  lost  but  little  blood,  but  reaction  did  not  come 


20  LECTURES  ON  PRACTICAL  SURGERY. 

on,  and  he  died  the  next  morning,  having  met  the  fate  he  anticipated 
and  so  much  dreaded. 

When  you  have  decided  that  surgical  interference  is  necessary,  and 
the  consent  of  the  patient  has  been  obtained,  the  operation  should  be 
performed  at  the  earliest  moment  possible.  Nothing  exerts  so  in- 
jurious an  effect  as  dread  and  suspense.  The  sleep  is  disturbed,  the 
secretions  are  deranged,  the  appetite  is  impaired,  and  in  many  cases 
the  delay  of  only  a  few  days  will  produce  so  much  constitutional 
disturbance  that  serious  consequences  may  follow  the  infliction  of 
a  slight  wound.  I  have  known  surgeons  of  great  eminence  who 
from  the  press  of  other  engagements  would  defer  from  day  to  day  an 
operation  which  was  regarded  as  necessary  and  even  indispensable, 
and  have  observed  the  effect  to  be  so  decidedly  injurious  that  I  have 
always  pursued  a  different  course,  and  have  never  had  reason  to 
regret  that  it  was  adopted. 

Always  operate  in  the  morning.  Nine  o'clock  is  the  hour  I  have 
selected,  and  then  if  secondary  haemorrhage  should  occur  it  can  be 
arrested  before  night.  Nothing  is  more  unpleasant  than  to  be 
obliged  to  ligate  a  bleeding  vessel  by  an  artificial  light. 

When  the  consent  of  a  patient  has  been  obtained,  and  the  time 
fixed,  be  careful  always  to  fulfil  your  engagement,  if  you  expect  to 
succeed.  By  procrastination  the  confidence  is  either  diminished  or 
the  impression  is  made  that  the  case  is  one  of  a  very  serious  char- 
acter, which  will  diminish  the  chance  of  success.  Should  the  gen- 
eral health  be  deranged,  before  any  definite  arrangement  is  made 
respecting  an  operation,  if  it  be  possible,  suitable  remedies  should  be 
administered,  and  a  proper  regimen  enjoined  to  remove  the  consti- 
tutional derangement  that  exists. 

In  order  to  diminish  the  shock  necessarily  resulting  from  oper- 
ations of  an  extensive  character,  an  anaesthetic  should  always  be 
administered,  and  the  only  reliable  agents  of  this  character  are  sul- 
phuric ether  and  chloroform.  The  choice  between  the  two  should 
depend  upon  the  character  of  the  case,  and  the  age  and  constitution 
of  the  patient.  If  the  operation  be  neither  very  painful  nor  tedious, 
and  the  patient  be  very  young  or  old  and  infirm,  then  I  think  ether 
alone  should  be  preferred. 

In  some  of  the  Eastern  hospitals  a  combination  of  one  part  of 
chloroform  to  three  parts  of  ether  is  employed,  because  it  acts  more 
promptly  than  the  ether  alone,  and  is  considered  less  dangerous  than 


LECTURE    I.  —  ANESTHETICS.  21 

chloroform.  When  the  constitutional  energy  is  not  too  much  im- 
paired by  disease,  and  the  operation  must  necessarily  be  both  painful 
and  tedious,  and  if  I  can  obtain  an  experienced  assistant  to  administer 
the  chloroform,  I  prefer  it  either  to  ether  alone  or  the  compound. 
It  is  prompt  in  its  action,  and  safe  when  properly  administered  and 
carefully  watched.  The  effect  is  more  durable,  and  the  sensibility 
of  the  patient  more  effectually  destroyed. 

Always  avoid  the  different  machines  that  have  been  invented  called 
inhalers,  because  they  do  not  permit  a  sufficient  quantity  of  atmos- 
pheric air  to  pass  into  the  lungs  with  the  chloroform,  to  render  its 
use  in  any  case  safe.  The  safest  and  most  simple  method  is  to  place 
-a  folded  towel  over  the  face,  and  apply  fifteen  or  twenty  drops  of 
chloroform  upon  the  external  fold  about  an  inch  below  the  nose,  and 
renew  the  application  as  often  as  it  becomes  necessary  by  evaporation, 
until  the  desired  effect  is  produced.  Dressing  forceps  should  always 
be  placed  near  the  assistant,  so  that  he  can,  should  the  breathing 
become  stertorous,  and  the  face  livid,  seize  the  tongue  and  prevent 
suffocation  by  its  retraction.  The  tongue  being  secured,  should  the 
respiration  remain  difficult,  or  cease  entirely,  sudden  and  sufficient 
pressure  should  be  made  upon  the  chest  to  expel  the  air  from  the 
lungs,  and  when  removed  it  generally  rushes  in  and  respiration  is 
again  established.  If  not,  the  effort  should  be  repeated,  and  if  inef- 
fectual, artificial  respiration  should  be  speedily  substituted.  When 
administered  as  directed,  and  with  the  precautions  recommended, 
chloroform  is  safe,  yet  I  must  acknowledge  that  an  extensive  expe- 
rience has  rendered  me  more  cautious  than  formerly,  and  I  now  think 
that  an  electro-magnetic  machine  should  always  be  at  hand  when  the 
protracted  use  of  chloroform  is  considered  necessary,  for  it  removes 
or  counteracts  the  anaesthetic  effect  with  more  certainty  than  any 
other  treatment  that  has  been  recommended. 

Caution  is  necessary  in  the  use  of  every  powerful  remedy,  and 
should  chloroform  appear  to  act  unkindly,  then  ether  should  be  sub- 
stituted to  keep  up  the  effect  so  long  as  may  be  necessary.  The 
inexperienced  should  always  employ  ether.  The  combination  ad- 
ministered carelessly  is  more  dangerous  than  either  separately.  It 
is  the  anaesthetic  I  employ  in  ordinary  cases,  particularly  if  my 
assistant  has  not  had  considerable  experience  in  the  administration 
of  chloroform. 

Anaesthetics  should  not  be  passed  over  hastily ;   they  are  to  the 


22  LECTURES    ON    PRACTICAL    SURGERY. 

surgeon  what  steam  and  the  telegraph  are  to  commerce  and  civiliza- 
tion, and  their  discoverer  deserves  as  lasting  a  monument  as  Morse 
or  Fulton.  No  doubt  will  be  entertained  of  the  truth  and  correct- 
ness of  this  assertion,  when  the  vast  amount  of  human  life  and 
suffering  that  have  been  saved  since  the  discovery  was  made  is  taken 
into  consideration.  They  render  incalculable  assistance  to  the  sur- 
geon. He  feels  that  he  can  operate  carefully  and  leisurely  without 
distressing  his  patient,  and  is  entirely  relieved  from  the  inconvenience 
resulting  from  the  resistance  the  bravest  are  unable  entirely  to  control. 

Never  make  a  display  of  instruments.  The  patient  should  not  be 
allowed  to  see  them,  because  it  has  a  demoralizing  and  consequently 
an  injurious  effect.  After  anaesthesia  has  been  induced,  select  such 
instruments  as  are  necessary,  and  place  them,  with  water,  sponges, 
bandages,  and  ligatures,  in  a  convenient  position.  Assign  to  each 
assistant  the  part  you  expect  him  to  perform,  so  that  hemorrhage 
may  be  promptly  arrested,  and  the  operation  completed  in  the  shortest 
time  possible  compatible  with  safety.  The  instruments  needed  are 
few  and  simple.  A  surgeon  could  hold  in  his  hand  almost  all  that 
are  necessary  to  perform  every  operation  in  surgery,  and  should  he 
visit  the  salesroom  of  an  instrument-maker,  he  would  only  be  as- 
tonished and  bewildered  by  the  number  and  variety  exhibited. 
Many  of  them  which  may  be  useful  to  the  young  and  inexperienced 
can  be  dispensed  with  by  the  surgeon.  I  would  advise  you  there- 
fore to  keep  but  few  instruments,  and  keep  them  well.  Always  carry 
with  you  a  small  pocket-case  which  contains  a  male  and  female 
catheter,  cutting  instruments,  needles,  and  ligatures,  and  then  you 
will  be  prepared  for  almost  any  emergency. 

After  an  operation  has  been  completed,  the  arteries  should  all  be 
secured,  and  then  if  union  by  the  first  intention  is  desired,  the  wound 
should  not  be  closed  for  at  least  an  hour  after  the  hemorrhage  has 
been  arrested.  The  edges  should,  after  being  perfectly  cleansed,  be 
approximated  and  retained  in  contact  by  the  interrupted  silver  suture. 
They  should  be  inserted  about  half  an  inch  apart,  and  if  the  wound 
be  deep,  at  least  half  an  inch  from  the  edges,  and  extend  if  possible 
to  its  entire  depth. 

Should  a  perfect  coaptation  not  result  from  the  sutures,  either  a 
narrow  strip  of  isinglass  or  common  adhesive  plaster  should  be 
applied  between  each  ;  or  what  may  be  preferable,  should  irrigation 
be  considered  necessary,  a  fine  suture  should  be  inserted  composed  of 


LECTURE    I.  —  DRESSING    OF    WOUNDS.  23 

common  sewing  silk,  which  should  be  removed  on  the  third  day,  to 
prevent  ulceration. 

It  is  customary  to  remove  all  the  sutures  on  the  third  or  fourth 
day ;  they  may,  however,  be  allowed  to  remain  seven  or  eight  days, 
or  longer,  and  even  until  the  wound  heals  by  granulation,  should 
union  by  the  first  intention  fail  to  occur. 

By  being  careful  to  secure  all  the  bleeding  vessels  with  ligatures 
which  correspond  with  them  in  size,  you  may  perform  thousands  of 
operations  without  in  a  single  case  being  compelled  to  remove  the 
dressings  for  the  purpose  of  arresting  hemorrhage,  which  is  always 
exceedingly  unpleasant  to  the  surgeon  and  decidedly  injurious  to  the 
patient.  After  the  wound  has  been  properly  closed,  apply  lint  wet 
with  warm  water,  which  should  be  covered  with  oiled  silk,  and  secured 
by  a  suitable  bandage.  This  dressing  should  be  changed  three  or  four 
times  a  day,  to  prevent  the  lint  adhering  to  the  wound  and  becom- 
ing an  obstacle  to  the  escape  of  the  secretions,  which  if  retained, 
would  render  union  by  the  first  intention  impossible.  Should  it  be 
found  from  the  location  of  the  part  inconvenient  to  make  this  appli- 
cation, then  simple  cerate  should  be  substituted.  When  union  by 
the  first  intention  is  not  desirable,  wet  lint  should  be  placed  between 
the  edges  of  the  wound  and  the  water  dressing  applied.  The  lint 
should  be  wet,  because  when  in  that  condition  it  does  not  adhere, 
and  will  allow  the  secretions  to  escape  readily,  and  when,  on  the 
third  day,  its  removal  becomes  necessary,  neither  pain  nor  difficulty 
will  be  experienced. 

So  soon  as  an  operation  is  completed,  and  before  the  haemorrhage 
has  been  arrested,  administer  a  full  dose  of  sulph.  morph.,  at  least 
half  a  grain  to  an  adult  male,  with  directions  to  repeat  half  the 
quantity  every  hour  until  it  affords  relief.  I  think  this  is  more  im- 
portant to  success  than  the  skilful  use  of  the  knife,  the  careful  ad- 
justment of  the  dressings,  or,  indeed,  everything  connected  with  the 
operation  combined.  Sometimes  after  a  tedious  and  difficult  opera- 
tion, reaction  does  not  take  place  readily ;  then  besides  the  morphia, 
brandy  should  be  administered,  and  the  patient  watched  until  reac- 
tion is  fully  established.  Morphia  in  such  cases  not  only  relieves 
pain  and  hastens  reaction,  but  also  prevents  inflammation,  and  is 
consequently  more  valuable  to  the  surgeon  than  every  other  agent 
within  his  control.  The  preceding  remarks  include  only  such  things 


24  LECTURES    ON    PRACTICAL    SURGERY. 

as  occur  in  every  operation,  and  to  avoid  repetition,  I  concluded  in 
the  first  lecture  to  refer  especially  to  them. 

Idiosyncrasy  is  another  subject  to  which  I  also  propose  to  direct 
your  attention.  This  is  a  peculiarity  of  constitution  which  causes  a 
medicinal  agent  to  produce  an  effect  different  from  that  generally 
expected  to  result  from  its  use.  Opium,  which  to  the  surgeon  is  the 
most  valuable  article  of  the  Materia  Medica  as  an  internal  remedy, 
occasionally  produces  violent  gastric  pain,  as  severe  as  that  experienced 
in  colic,  which  continues  so  long  as  it  remains  in  the  stomach.  It 
would  therefore  be  exceedingly  important,  before  performing  a  dan- 
gerous operation,  to  ascertain  whether  any  such  peculiarity  exists. 
During  the  preliminary  treatment  some  preparation  of  opium  should 
be  administered,  and  if  the  effect  is  not  satisfactory,  experience  has 
taught  me  that  in  such  cases  it  may  be  applied  endermically  with 
the  most  happy  result. 

Mercurials  also  act  very  unfavorably  in  some  cases.  They  not 
only  produce  sickness  of  the  stomach  and  even  violent  vomiting,  but 
also  the  most  distressing  ptyalism,  or  salivation,  as  it  is  usually 
called.  This  effect  may  be  produced  by  the  smallest  quantity,  and 
is  always  unpleasant,  and  might,  under  certain  circumstances,  be  ex- 
ceedingly injurious;  because  it  is  usually  accompanied  with  fever  and 
a  profuse  and  offensive  salivary  secretion,  which  renders  it  impossible 
for  sufficient  sleep  to  be  obtained. 

Ol.  ricini,  which  is  generally  regarded  as  a  mild  and  simple  pur- 
gative, sometimes  produces  the  most  distressing  tenesmus,  and  con- 
sequently should  be  avoided,  unless  it  had  been  previously  adminis- 
tered, and  found  to  produce  its  usual  effect.  In  consequence  of  the 
poisonous  properties  of  shell-fish,  particularly  if  they  are  not  fresh, 
they  should  be  positively  prohibited,  so  long  as  any  unfavorable 
effect  that  might  result  from  their  use  could  be  attributed  to  the 
operation. 

Many  patients  are  lost  by  proper  attention  not  being  paid  to  the 
subsequent  treatment.  Before  closing  this  lecture  I  will  direct  your 
attention  to  other  difficulties,  which  may  assume  a  very  serious  char- 
acter after  injuries,  extensive  operations,  compound  fractures,  contused 
wounds,  erysipelas,  or  any  disease  by  which  a  patient  may  be  con- 
fined in  a  recumbent  position  for  four  or  five  weeks  consecutively. 

1st.  Congestion  is  an  inordinate  or  unnatural  accumulation  of 
blood  in  the  vessels  of  any  part  of  the  body,  and  may  result  either 


LECTURE    I.  —  CONGESTION.  25 

from  an  increased  action  of  the  arteries  by  which  it  is  supplied  with 
blood,  or  from  venous  obstruction. 

The  former  is  called  active  congestion,  and  the  latter  passive.  In 
the  active  form,  the  vessels  are  distended,  the  part  is  red  and  pre- 
sents the  appearance  of  being  inflamed  without  exhibiting  any  of  the 
other  indications  of  that  affection,  although  they  may  occur  at  any 
moment,  as  that  is  usually  the  condition  a  part  presents  before  the 
development  of  acute  inflammation.  In  passive  congestion,  the  part 
is  generally  livid,  and  somewhat  swollen,  in  consequence  of  an  accu- 
mulation of  venous  blood.  It  occurs  frequently  in  the  lower  ex- 
tremities, and  depends  on  or  is  produced  by  a  dilatation,  elongation, 
and  thickening  of  the  veins.  The  valves  in  consequence  of  the  di- 
latation do  not  perform  their  function,  and  if  proper  treatment  is  not 
adopted,  the  integument  inflames,  is  absorbed,  and  a  very  trouble- 
some ulceration  is  the  consequence. 

The  form,  however,  of  passive  congestion  to  which  I  now  desire 
particularly  to  direct  your  attention,  is  that  which  occurs  in  the  pos- 
terior portion  of  the  lungs,  produced  by  confinement  upon  the  back 
sufficiently  long  for  the  blood  to  accumulate  in  that  portion  of  the 
respiratory  apparatus  by  gravitation.  In  a  case  of  fracture  of  the 
neck  of  the  femur  which  occurred  in  this  city  a  few  years  since,  in 
which  the  patient  was  confined  too  long,  after  complaining  a  few 
days  of  difficulty  of  breathing,  he  was  attacked  with  haemorrhage 
from  the  lungs.  The  splint  was  then  removed  and  his  position 
changed.  The  congestion  soon  disappeared,  and  he  is  now  in  good 
health. 

This  should  be  carefully  guarded  against,  and  being  aware  that 
danger  may  arise  from  such  a  source,  we  should  always,  so  soon  as 
the  condition  of  the  patient  will  permit,  insist  on  a  frequent  change  of 
position,  in  order  to  avoid  congestion,  as  well  as  bed-sores,  which  are, 
although  more  annoying,  unless  extensive,  much  less  dangerous.  In 
the  latter  affection,  before  the  skin  ulcerates,  it  by  position  becomes 
congested ;  if  that  is  not  relieved  it  inflames,  and  ulceration  follows, 
an  event  which  is  always  annoying  to  the  patient  and  exceedingly 
troublesome  to  the  physician.  These  serious  and  too  common  com- 
plications can  almost  always  be  prevented  by  proper  attention. 

In  erysipelas  as  well  as  in  every  other  protracted  disease,  the  po- 
sition should  be  changed  as  frequently  as  possible,  to  prevent  con- 
gestion, not  only  of  the  lungs,  but  also  of  other  important  organs. 


26  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE    II. 

GENTLEMEN  :  For  the  same  reason  before  assigned  for  introducing 
idiosyncrasy,  I  to-day  propose  to  say  a  few  words  about  sympathy, 
irritation,  irritants,  etc. 

By  sympathy  we  understand  the  connection  that  exists  between 
two  or  more  separate  organs,  by  which  the  disease  of  one  is  trans- 
mitted secondarily  to  the  other.  The  knowledge  of  the  sympathetic 
relation  of  organs  is  of  great  importance  in  the  practice  of  both 
medicine  and  surgery.  For  convenience  it  is  divided  as  follows: 

1st.  Sympathy  of  contiguity. 
2d.  Sympathy  of  continuity. 
3d.  Remote  sympathy. 

It  is  not  surprising  that  organs  in  close  proximity  should  take  on 
either  the  same  diseased  action  or  suffer  greater  or  less  derangement 
of  function,  in  consequence  of  the  existence  of  disease  in  a  neighbor- 
ing organ.  In  haemorrhoids,  after  the  tumors  have  been  strangulated 
by  the  application  of  a  ligature,  an  inability  to  pass  the  urine  fre- 
quently follows  the  operation  so  soon,  that  the  derangement  of  the 
function  of  the  bladder  could  not  result  from  inflammation,  and  can 
only  be  explained  by  attributing  it  to  contiguous  sympathy. 

When  a  calculus  is  passing  from  the  kidney  to  the  bladder,  the 
pain,  always  excruciating,  is  greatly  aggravated  by  a  violent  contrac- 
tion of  the  spermatic  cord,  with  a  retraction  of  the  testicle.  This 
occurs  in  every  case  of  this  character,  and  cannot  be  otherwise  satis- 
factorily explained. 

Continuous  Sympathy. — When  a  patient  has  gonorrhoea,  and  either 
is  badly  treated,  has  taken  violent  exercise,  or  has  lived  imprudently, 
the  discharge  frequently  ceases  suddenly,  and  the  inflammation  ex- 
tends either  to  the  bladder  or  testicles,  and  produces  a  difficulty  much 
more  serious  than  the  original,  and  when  that  is  relieved,  all  the 
symptoms  of  gonorrhoea  return. 

After  any  operation  for  the  removal  of  hsemorrhoidal  tumors,  the 
inflammation  may  extend  from  the  lower  extremity  of  the  rectum 


LECTURE    II.  —  IRRITATION.  27 

upwards,  until  the  mucous  membrane  becomes  so  extensively  and 
seriously  involved  as  to  prove  speedily  fatal. 

AYhen  an  organ  distant  from  the  one  diseased  becomes  affected,  it 
is  said  to  depend  on  remote  sympathy,  which  may  result  from  nervous 
connection,  or  from  both  organs  being  engaged  in  the  same  function. 
When  the  uterus  is  ulcerated  or  otherwise  diseased,  the  mammae 
sometimes  become  so  enlarged,  and  are  so  painful,  that  they  attract 
more  attention  than  the  organ  in  which  the  disease  exists. 

The  same  sympathetic  connection  exhibited  between  the  uterus 
and  mammae,  is  known  to  exist  between  the  parotid  gland  and  testi- 
cles, and  as  in  the  preceding  example,  the  sympathetic  affection  is 
much  more  serious  than  the  original  difficulty.  The  sympathetic 
relations  that  exist  between  all  the  different  organs  of  the  body 
would  be  enumerated,  if  it  were  not  an  intrusion  upon  the  rights  of 
the  professor  of  the  theory  and  practice  of  medicine. 

Irritation  or  Increased  Determination. — Whenever  the  vital  action 
of  a  part  is  excessive,  indicated  by  increased  sensibility  and  vascular 
fulness,  it  is  said  to  be  irritated.  Irritation  differs  in  degree,  and 
its  character  depends  on  the  nature  of  the  irritant  applied,  and  the 
constitutional  effect  depends  upon  the  extent  of  the  irritated  surface. 

When  a  gentle  irritant  is  applied  to  a  secreting  surface,  the  natural 
secretion  is  increased.  The  presence  of  tobacco  in  the  mouth  and 
nose  will  increase  the  activity  both  of  the  salivary  glands  and  the 
Schneiderian  membrane.  A  drop  of  alcohol,  a  solution  of  alum 
or  nitrate  of  silver,  applied  to  the  eye,  increases  the  action  of  the 
lachrymal  glands,  and  a  profuse  secretion  is  the  result,  which  will 
soon  subside  when  the  cause  is  removed.  Condiments  have  the  same 
effect  both  on  the  raucous  membrane  of  the  mouth  and  stomach. 
If  applied  frequently,  the  sensibility  of  the  part  is  diminished,  and 
they  ultimately  become  indispensable  to  enable  the  organ  to  perform 
its  function.  They  may  become  the  cause  of  disease,  and  conse- 
quently should  be  avoided. 

Irritants  are  valuable  remedies,  both  to  the  surgeon  and  physician, 
and  you  cannot  be  too  familiar  with  the  articles  employed,  the  pecu- 
liarity of  their  action,  and  the  extent  to  which  they  may  be  judi- 
ciously carried.  You  should  avoid  the  use  of  powerful  irritants  in 
the  treatment  of  the  diseases  both  of  children  and  delicate  women. 
As  a  local  irritant  for  young  children,  flannel  wet  with  warm  vinegar, 
covered  with  oiled  silk,  and  renewed  three  or  four  times  in  twenty- 


28  LECTURES    ON    PRACTICAL    SURGERY. 

four  hours,  is  superior  to  anything  that  can  be  applied.  It  irritates 
moderately,  and  even  sometimes  vesicates  slightly,  if  continued  three 
or  four  days,  and  then  the  warm  water  dressing  may  be  substituted. 
In  such  cases  I  rarely  make  a  more  active  application,  for  when  the 
vinegar  is  strong  and  properly  applied,  it  fulfils  the  indication. 

In  the  treatment  of  the  diseases  of  females,  never  apply  tartar 
emetic  ointment.  The  distress  resulting  from  its  use  produces  fever, 
and  it  fails  to  aiford  the  relief  anticipated. 

If  counter-irritation  be  necessary  in  such  cases,  apply  twenty  drops 
of  croton  oil,  and  rub  it  in  well  with  coarse  paper.  It  should  not 
be  applied  to  too  extensive  a  surface,  nor  repeated  after  the  peculiar 
eruption  begins  to  appear. 

When  a  blister  is  required,  nothing  is  equal  to  Birt's  blistering 
fluid.  It  rarely  produces  strangury,  and  it  vesicates  in  three  or  four 
hours.  It  is  less  painful  than  blistering  ointment,  and  as  a  counter- 
irritant,  is  equally  as  efficacious.  The  warm  water  dressing  should 
be  applied,  and  continued  until  the  blister  heals.  It  is  always  better 
to  reapply  the  fluid  than  to  resort  to  irritating  substances,  either  to 
increase  or  protract  the  discharge  from  a  blistered  surface. 

Many  think  that  if  a  small  blister  be  useful,  the  benefit  will  in- 
crease with  the  extent  of  the  blistered  surface,  an  opinion  which  is 
as  erroneous  as  could  be  entertained.  Large  blisters  are  exceedingly 
injurious,  in  consequence  of  the  constitutional  disturbance  resulting 
from  the  irritation  of  so  extensive  a  surface.  They  become  also,  in 
delicate  and  emaciated  subjects,  exceedingly  debilitating,  from  the 
great  quantity  of  serum  as  well  as  pus  that  may  be  secreted  by  the 
denuded  surface.  Never  vesicate  larger  than  six  inches  square,  it 
being  better  to  reapply  the  fluid  in  a  few  days  than  to  blister  a  larger 
surface. 

A  great  variety  of  rubefacients  are  employed,  many  of  which  are 
useful  counter-irritants,  and  will  receive  the  attention  they  respec- 
tively deserve,  when  they  are  considered  especially  applicable  to  the 
disease  under  consideration.  The  more  active  will  be  included  under 
the  head  of  poisons,  and  the  peculiarity  of  their  action  more  partic- 
ularly described. 

The  diseases  which  belong  to  the  department  of  surgery  always 
present  structural  derangements,  except  when  foreign  bodies  have 
been  introduced  into  the  nares,  ears,  or  air-passages,  or  form  in  the 
ducts  of  the  salivary  glands,  or  in  the  internal  cavities  by  a  deposi- 


LECTURE    II. — INFLAMMATION.  29 

tion  from  the  fluid  they  usually  contain,  as  gallstones  and  urinary 
calculi.  These  structural  derangements  may  result  from  mechanical 
violence,  which  include  wounds,  contusions,  and  every  casualty  to 
which  the  human  body  is  exposed.  They  may  also  result  from 
deranged  nutrition,  and  as  the  structural  lesions,  except  those  speci- 
fied, are  produced  by  inflammation,  that  should  next  be  considered. 

What  is  inflammation?  The  following  is  the  best  definition 
which  I  can  give  you.  It  is  a  disturbance  of  the  nervous  energy, 
accompanied  with  a  perverted  action  of  the  capillary  system,  gener- 
ally attended  with  increased  heat,  pain,  redness,  and  swelling.  Some 
think  that  the  most  important  element  is  the  perversion  of  the  vital 
action  of  the  part  affected.  This  is  "  considered  essential  and  never 
failing.'7 

Inflammation  forms  a  very  important  subject  in  surgery,  and 
consequently  should  receive  your  especial  attention. 

It  may  be  divided  into  healthy  and  unhealthy  inflammations.  By 
the  agency  of  the  former  all  wounds  are  healed  and  injuries  repaired; 
without  it  no  ulcer  would  granulate  and  cicatrize,  and  consequently 
every  operation  performed  on  the  human  body  must  necessarily  prove 
fatal.  When  healthy  it  is  the  surgeon's  friend.  If  not  well  under- 
stood, however,  and  properly  treated,  it  may  become  unhealthy,  and 
then  consequences  more  or  less  serious  and  alarming  must  result. 
When  the  nervous  shock  is  not  sufficient  to  destroy  life  before  reac- 
tion occurs,  every  injury  is  followed  by  inflammation,  which  may 
become  beneficial  or  destructive  in  proportion  to  its  character  and 
violence. 

The  symptoms  of  inflammation  are  both  local  and  constitutional. 
The  local  symptoms  are,  1st.  Heat.  A  burning  sensation  is  not 
only  experienced  in  the  part  affected,  but  the  temperature  is  also 
elevated  notwithstanding  the  opposite  opinions  of  Hunter  and  other 
distinguished  pathologists,  who,  after  experimenting  extensively, 
arrived  at  the  conclusion  that  it  did  not  exceed  that  of  the  centre  of 
the  body.  The  experiments  of  Professor  Gross,  Andral,  and  others, 
prove  conclusively  that  the  temperature  of  an  inflamed  part  fre- 
quently reaches  106°  Fahrenheit,  and  also,  that  if  the  inflamed 
surface  is  not  exceedingly  limited,  the  temperature  is  always  in- 
creased. This  elevation  of  temperature  results  from  the  increased 
action  of  the  heart  and  arteries,  and  may  depend  both  on  the  friction 
resulting  from  the  blood  passing  rapidly  through  the  vessels,  and 


30  LECTURES    ON    PRACTICAL    SURGERY. 

the  increased  oxygenation  produced  by  the  accelerated  respiration 
which  always  accompanies  increased  arterial  action. 

When  the  action  of  the  heart  is  increased  the  heat  of  the  body  is 
always  elevated ;  but  so  soon  as  the  former  is  diminished  by  the  ad- 
ministration of  proper  remedies,  both  the  respiration  and  heat  become 
normal. 

If  increased  vascular  action  elevates  the  temperature  of  the  body 
we  may  reasonably  conclude  that  in  inflammation,  so  long  as  the 
temperature  is  elevated,  the  action  of  the  vessels  in  the  part  affected 
is  also  increased.  Volumes  have  been  written  upon  this  subject 
without  contributing  anything  either  to  the  pathology  or  treatment 
of  inflammation. 

The  point  then  in  controversy  was,  Does  more  blood  pass  through 
the  vessels  of  an  inflamed  part  than  when  it  is  in  a  natural  and 
healthy  condition  ? 

The  vessels  circulate  more  blood  so  long  as  the  action  is  purely 
inflammatory,  and  less  for  a  short  time  before  the  termination  or 
result  becomes  manifest. 

2d.  Pain  almost  always  exists  in  inflammation,  and  is  generally 
in  proportion  to  the  violence  of  the  diseased  action  and  the  sensi- 
bility of  the  part  affected. 

When  serous  membranes  are  inflamed,  as  the  pleura  and  perito- 
neum, the  pain  is  sharp  and  lancinating ;  but  when  the  body  of  an 
organ,  as  the  liver,  becomes  inflamed,  the  pain  is  less  acute,  and  is 
described  as  being  of  a  dull  and  throbbing  character.  In  consequence 
of  the  great  sensibility  of  the  eye,  the  pain  is  acute  and  lancinating, 
but  not  so  violent  as  that  experienced  in  otitis  and  in  inflammation 
of  the  frontal  sinus,  which  is  usually  mistaken  for  and  called  neural- 
gia. It  is  intermittent  and  resists  the  action  of  the  remedies  usually 
prescribed  in  such  cases,  and  indeed  everything  fails  to  give  relief 
except  the  endermic  use  of  morphia.  The  pressure  to  which  the  in- 
flamed mucous  membrane  is  subjected,  by  the  parietes  of  the  frontal 
sinus  and  the  bony  structure  of  the  ear,  accounts  for  the  violence  of 
the  pain  in  these  affections. 

When  mucous  membranes  are  inflamed  the  pain  is  of  a  burning 
or  scalding  character,  as  in  inflammation  of  the  bladder,  urethra, 
or  rectum.  Pain  is  not  always  felt  in  the  part  affected.  When 
the  bladder  is  inflamed  by  the  presence  of  a  calculus  the  pain  is 
always  greatest  at  or  near  the  glans  penis. 


LECTURE    II.  —  INFLAMMATION.  31 

When  the  kidneys  are  diseased  the  patient  suffers  more  from  a 
burning  sensation  near  the  extremity  of  the  urethra  than  in  the 
organs  affected.  It  is  necessary  to  understand  the  difference  between 
the  pain  resulting  from  spasm,  distension,  and  inflammation.  When 
a  gallstone  is  passing  through  the  dtictus  communis  choledochus,  or 
a  urinary  calculus  through  the  ureters,  the  pain  is  more  excruciating 
even  than  that  experienced  in  inflammation  of  the  ear,  frontal  sinuses, 
or  teeth.  In  a  case  treated  some  years  since,  during  the  passage  of 
a  gallstone,  the  pain  was  so  violent  as  to  produce  convulsions,  and 
was  only  palliated  by  venesection,  the  warm  bath,  and  the  adminis- 
tration, in  less  than  two  hours,  of  an  ounce  of  the  tincture  of  opium. 

In  neuralgia,  which  is  a  much-abused  word,  the  pain  is  sharp, 
lancinating,  and  generally  intermits.  It  is  not  accompanied  by  the 
ordinary  indications  of  inflammation,  and  the  pain  is  always  re- 
lieved by  pressure.  Instances  of  this  affection  are  exceedingly  rare, 
although  they  occasionally  occur.  Almost  all  that  receive  that  name 
and  are  treated  as  purely  nervous,  depend  on  inflammation,  either 
of  the  part  complained  of,  or  of  the  nerves  by  which  it  is  supplied, 
or  else  arise  from  sympathy  with  either  a  contiguous  or  distant  suf- 
fering organ. 

Patients  suffer  very  differently  from  the  same  degree  of  inflam- 
mation, a  circumstance  which  depends  on  a  peculiarity  of  organiza- 
tion called  idiosyncrasy.  Sometimes,  when  inflammation  and  ulcer- 
ation  exist,  but  little  pain  is  experienced,  as  in  typhoid  fever. 
There  is  generally  some  tenderness  on  pressure  being  made  over  the 
inflamed  intestine,  but  not  sufficient  to  attract  the  attention  of  the 
patient,  or  excite  the  apprehension  of  the  physician. 

Pain  results  generally  both  from  the  pressure  made  by  the  dis- 
tended bloodvessels  on  the  accompanying  nerves,  and  from  inflam- 
mation of  nerves  themselves.  It  is,  in  inflammation,  fortunately 
rarely  absent,  and  is  great  in  proportion  to  the  violence  of  the  in- 
flammatory action.  It  is  the  most  useful  and  valuable  guide  to  the 
surgeon  in  the  selection  of  proper  remedies ;  and  it  compels  the 
patient  to  remain  in  the  most  favorable  position,  which  has  great 
influence  in  such  cases  either  to  increase  or  alleviate  pain.  This 
is  strikingly  illustrated  both  in  whitlow,  and  in  inflammation  and 
ulceration  of  the  lower  extremities. 

3d.  Redness. — As  this  is  produced  by  the  distension  of  the  blood- 
vessels, and  particularly  those  which  do  not  usually  circulate  red 


32  LECTURES    ON    PRACTICAL    SURGERY. 

blood,  it  must  necessarily  vary  in  hue  from  the  lightest  pink  to  the 
deepest  purple,  according  to  the  peculiarity  of  the  part  inflamed, 
and  the  violence  and  character  of  the  morbid  action. 

The  livid  appearance  presented  in  derangements  of  the  respiratory 
function,  and  in  ecchymosis,  particularly  after  operations  on  the 
genital  organs,  or  in  cases  where  an  obstruction  or  interruption  of 
the  venous  circulation  of  the  part  exists,  should  not  be  mistaken  for 
and  treated  as  one  of  the  most  serious  terminations  of  inflammation. 

The  redness  of  the  conjunctiva,  when  inflamed,  results  from  the 
presence  of  red  blood  in  vessels  which  in  a  healthy  condition  never 
receive  the  red  globules.  In  other  organs,  the  intensity  of  the  color 
depends  on  the  vascularity  of  the  part  affected  It  is  very  conspicu- 
ous in  inflammation  of  the  skin,  the  mucous  and  serous  membranes, 
as  well  as  in  inflammatory  affections  of  the  viscera  both  of  the  chest 
and  abdomen ;  on  the  contrary,  in  inflammation  of  the  bones,  liga- 
ments, and  tendons,  and  particularly  the  latter,  red  vessels  can  with 
difficulty  be  detected,  even  when  the  inflammation  is  so  violent  as  to 
destroy  the  vitality  of  the  part  in  a  few  days.  The  same  is  true  in 
inflammation  of  the  cornea,  an  ulcer  frequently  appearing  upon  the 
corneal  surface,  particularly  in  strumous  ophthalmia,  without  being 
preceded  by  much  redness  even  of  the  conjunctiva. 

The  character  of  the  inflammation  may  generally  be  determined 
by  the  color  presented.  It  is  bright  red  when  located  in  the  skin  or 
throat,  brown  in  iritis,  and  yellowish  or  copper-colored  in  secondary 
syphilitic  affections.  The  edges  of  a  scrofulous  ulcer  are  usually 
livid  and  elevated,  and  when  mortification  takes  place,  the  part  im- 
plicated is  always  grayish  or  black. 

The  discoloration  resulting  from  inflammation  is  named  according 
to  the  appearance  it  presents;  when  extensive,  it  is  said  to  be  diffuse ; 
linear,  when  long,  narrow,  and  following  the  course  of  the  veins  or 
lymphatics;  macufiform,  when  it  presents  the  appearance  of  a  stain  or 
blotch  ;  punctiform,  when  small  and  distinct  points  of  the  skin  or 
mucous  membrane  are  only  diseased;  and  arborescent,  when  it  spreads 
from  a  centre,  like  the  branches  from  the  trunk  of  a  tree,  or  the 
veins  from  the  common  stem  of  a  leaf. 

4th.  Swelling. — This  results  from  the  distension  of  the  bloodvessels 
and  the  effusion  into  the  cellular  tissue,  separately  or  conjointly,  of 
serum  and  coagulable  lymph,  which  is  the  albuminous  part  of  the 
blood.  The  amount  of  swelling  depends  on  the  part  affected. 


LECTURE    II.  —  INFLAMMATION.  33 

Bones,  fibrous  tissue,  vessels,  and  nerves,  as  well  as  the  cornea  and 
sclerotic  membranes  of  the  eye,  and  most  of  the  viscera,  do  not  swell 
so  rapidly  and  extensively  as  do  the  scrotum,  vulva,  conjunctiva,  glot- 
tis, tonsils,  and  the  upper  part  of  the  face,  in  consequence  of  the  latter 
being  abundantly  supplied  with  cellular  tissue.  An  inflamed  part 
generally  enlarges  slowly,  and  sometimes  the  swelling  only  appears 
when  the  diseased  action  is  disappearing ;  and  it  depends  on  the  effu- 
sion of  serum,  by  which  the  distension  of  the  vessels  is  relieved. 

It  occasionally,  however,  increases  with  great  rapidity,  as  after 
severe  injuries,  the  sting  of  poisonous  insects,  the  bite  of  the  rattle- 
snake, or  the  action  of  both  vegetable  and  mineral  poisons.  Swellings 
difter  in  character.  When  soft,  they  depend  either  on  the  simple 
dilatation  of  the  bloodvessels,  or  the  effusion  of  serum  in  the  cellular 
tissue.  When  firm  or  solid,  they  are  generally  produced  by  the 
effusion  and  organization  of  plastic  lymph.  They  may  be  either 
beneficial  or  injurious;  beneficial,  when  the  secretion  of  serum  de- 
pletes the  inflamed  and  distended  vessels ;  injurious,  when  the  tumor, 
by  its  size,  disturbs  the  circulation  so  much  as  to  produce  strangula- 
tion and  death,  as  in  the  cornea  when  the  conjunctiva  is  violently 
inflamed ;  and  as  in  suffocation,  when  the  glottis  is  so  much  swollen 
as  to  prevent  the  admission  of  atmospheric  air  into  the  lungs. 

Functional  Derangement. — By  function  we  understand  the  office 
performed  by  every  distinct  organ  or  tissue  of  the  human  body. 

When  the  organ  is  inflamed,  the  function  is  always  imperfectly 
performed,  and  frequently  entirely  suspended.  This  applies  to  ab- 
sorption as  well  as  to  the  other  functions. 

The  sensibility  in  such  cases  is  always  greatly  increased,  which  is 
as  apparent  when  pressure  is  made  in  gastritis,  peritonitis,  and  enter- 
itis, as  in  carbuncle,  erysipelas,  and  hsemorrhoidal  tumors.  Parts 
destitute  of  sensibility,  such  as  bones,  tendons,  and  fibrous  tissue, 
when  inflamed,  become  exceedingly  sensitive.  There  is  also  an  in- 
crease of  irritability,  particularly  -of  the  viscera  of  the  abdomen. 
The  stomach,  when  inflamed  itself,  or  when  any  of  the  digestive 
organs  are  suffering  from  acute  inflammation,  frequently  becomes 
so  irritable  that  nothing  can  be  retained;  this  irritability  of  the 
muscular  coats  of  the  bladder  and  intestines  is  a  source  of  great 
distress  both  in  cystitis  and  enteritis. 

Causes  of  Inflammation. — These  should  be  divided  into  the  predis- 

3 


34  LECTURES    ON    PRACTICAL    SURGERY. 

posing  and  exciting  causes,  and  the  former  are  either  natural  or  ac- 
quired. 

To  the  natural  predisposing  causes  belong  hereditary  constitutional 
peculiarities,  which  render  the  subject  more  susceptible  to  gout, 
rheumatism,  and  scrofula,  when  exposed  to  the  exciting  causes,  than 
if  no  such  predisposition  or  constitutional  peculiarity  existed.  To 
the  acquired  predisposing  causes  belong  such  as  result  from  tem- 
perament, occupation,  age,  and  excesses  of  every  description.  What- 
ever has  a  tendency  to  impair  the  health  by  deranging  the  secretions 
predisposes  to  inflammation. 

Exciting  Causes. — These  are  numerous,  and  may  be  divided  into 
local  and  constitutional  causes,  or  into  those  which  are  applied  to 
the  part  affected,  and  those  which  act  through  the  general  system. 
The  local  causes  are  either  chemical  or  mechanical;  as  examples  of  the 
former  may  be  mentioned  heat,  acids,  alkalies,  tartarized  antimony, 
corrosive  sublimate,  ol.  tiglii,  rubefacients,  blisters,  and  every  agent 
which  acts  promptly  and  violently.  The  mechanical  local  causes  are 
wounds,  contusions,  dislocations,  and  fractures,  as  well  as  distension 
of  the  ligaments  of  the  joints  or  the  urinary  bladder.  A  foreign 
body  either  in  the  air-passages  or  any  other  portion  of  the  body  may 
produce  inflammation. 

Constitutional  Exciting  Causes. — It  is  impossible  to  determine  the 
modus  operandi  of  many  of  these  agents.  Cold  and  heat  are  the 
most  prolific  of  all.  The  former  produces  inflammation  of  the  throat 
and  respiratory  organs,  and  the  latter  diseases  of  the  liver  and  other 
abdominal  viscera. 

Excessive  hemorrhage  from  any  cause,  as  well  as  extensive  and 
violent  contusions,  either  from  firearms  or  other  weapons,  are  always 
serious,  and  may  be  followed  by  violent  inflammation. 

It  may  also  result  both  from  sympathy  and  metastasis ;  from  sym- 
pathy, as  in  ophthalmia,  because  the  organs  are  engaged  in  the  same 
function;  from  metastasis,  when  inflammation  appears  either  in  a 
contiguous  or  distant  organ,  soon  after  disappearing  suddenly  from 
its  original  position,  as  when  the  brain  becomes  diseased  from  a 
metastasis  from  the  scalp. 

Constitutional  Disturbance. — This  depends  both  on  the  character 
and  extent  of  the  diseased  action.  When  limited  and  located  in  an 
unimportant  part,  it  is  not  recognized  by  the  system,  but  when 
extensive,  even  if  not  intense,  violent  constitutional  symptoms,  called 


LECTURE    II.  —  CONSTITUTIONAL    DISTURBANCE.  35 

fever,  are  produced,  which  may  be  either  sthenic  or  asthenic.  The 
latter  is  usually  called  typhoid.  t 

When  persons  in  good  health,  and  not  advanced  in  life,  are  exposed 
to  the  causes  by  which  inflammation  is  usually  produced,  for  a  greater 
or  less  period,  which  depends  on  the  activity  of  the  cause  and  the 
vitality  and  vascularity  of  the  part,  they  complain  of  aching  and 
feebleness  of  the  lower  extremities,  pain  in  the  back,  chilliness,  head- 
ache, loss  of  appetite,  and  indeed  of  all  the  symptoms  which  precede 
a  paroxysm  of  malarious  fever.  In  such  cases  the  chill  is  generally 
short,  and  is  followed  by  fever,  which  is  characterized  by  a  full, 
strong,  and  frequent  pulse,  increased  heat  of  the  entire  surface  of 
the  body,  great  thirst,  violent  pain  in  the  head,  hurried  respiration, 
and  a  disturbance  of  all  the  secretions.  No  benefit  would  result 
from  the  enumeration  and  specification  of  the  precise  change  which 
each  undergoes  in  such  cases,  even  if  it  were  possible. 

When,  however,  peritonitis  exists,  the  pulse  is  usually  hard,  small, 
and  quick ;  and  if  there  were  not  great  pain  and  tenderness  on  pres- 
sure, the  pulse  alone  might  deceive  the  inexperienced,  and  cause  an 
improper  course  of  treatment  to  be  adopted.  This  form  of  fever 
usually  remits  in  the  morning,  and  always  increases  during  the  af- 
ternoon and  evening.  Should  it  remain  uncontrolled,  the  fever  will 
continue  and  the  strength  decline,  until  the  symptoms  become  either 
typhoid  or  hectic,  according  to  the  character  of  the  local  difficulty. 

Asthenic  inflammatory  fever  results  from  the  same  causes  as  the 
preceding,  the  eifect  being  modified  by  the  constitution  of  the  patient. 
The  dissipated,  badly  fed,  and  crowded  residents  of  large  cities, 
are  particularly  liable  to  this  form  of  fever,  which  is  much  more 
serious  and  fatal  than  the  sthenic.  The  period  of  depression  is  de- 
cided, and  sometimes  protracted,  and  when  reaction  does  take  place, 
the  pulse  is  teeble  and  quick.  The  heat  of  the  body,  particularly  of 
the  chest,  is  pungent.  The  tongue  is  sometimes  brown  and  dry,  but 
more  frequently  pointed  and  red.  The  cheeks  are  generally  flushed, 
and  the  teeth  very  soon  become  covered  with  sordes.  Delirium 
occurs  early,  and  may  be  accompanied  either  by  stupor  or  by  inability 
to  sleep. 

When  symptomatic  fever,  whether  of  sthenic  or  asthenic  form, 
terminates  favorably,  critical  evacuations  frequently  occur,  such  as 
profuse  perspiration,  diarrhoea,  or  haemorrhage ;  but  fatal  coma  and 
death  are  preceded  by  subsultus,  hiccough,  dyspnoea,  and  coldness  of 


36  LECTURES    ON    PRACTICAL    SURGERY. 

the  surface,  which  are  all  produced  by  one  or  more  of  the  internal 
organs  becoming  implicated. 

In  inflammation  the  blood  undergoes  several  changes.  The  most 
important  and  decided  is  an  increase  of  fibrin  and  the  number  of 
the  colorless  globules.  Pathologists  give  the  proportion  of  fibrin  to 
the  entire  mass  of  blood  as  3  to  1000 ;  but  in  inflammation  it  may 
be  as  high  as  9  or  10  to  1000.  It  is  believed  that  the  quantity 
continues  to  increase  until  the  inflammation  begins  to  subside;  then 
it  diminishes  in  the  same  ratio.  In  consequence  of  the  increase  of 
fibrin,  when  blood  is  drawn  rapidly  from  a  vein,  particularly  if  it 
falls  into  a  deep  and  narrow  vessel,  the  blood  presents  what  is  called 
the  buffy  coat.  This  is  a  grayish  substance  which  contains  no  red 
globules,  and  rises  to  the  surface  as  the  blood  coagulates.  It  is  some- 
times cupped  or  depressed  in  the  centre,  and,  except  in  pregnancy, 
it  rarely  occurs  unless  in  inflammatory  affections 

Nature  of  Inflammation. — Before  proceeding  with  the  consideration 
of  this  subject,  I  beg  leave  to  direct  your  attention  to  the  blood,  the 
capillaries,  and  nerves,  as  they  are  the  active  agents  in  the  production 
of  this  common  but  dangerous  affection.  When  blood,  after  leaving 
a  vein,  coagulates,  it  is  found  to  contain  both  a  fluid  and  solid  por- 
tion. The  first  is  called  serum,  and  the  latter  crassamentum.  The 
crassamentum  consists  of  a  pale,  transparent  fluid,  called  liquor 
sanguinis,  plasma,  or  coagulable  lymph,  which  contains  both  red  and 
white  globules.  The  red  are  about  -g^^  of  an  inch  in  diameter, 
and  the  white  are  not  only  larger,  but  are  also  more  adhesive,  circu- 
lating more  slowly  and  nearer  the  walls  of  the  vessels. 

The  Capillaries. — These  are  the  minute  vessels  which  intervene 
between  the  arteries  and  veins.  Some  of  them  are  sufficiently  large 
to  allow  red  blood  to  pass  through  them  readily,  while  from  others 
it  is  entirely  excluded,  except  when  the  part  is  inflamed.  These 
vessels  perform  a  very  important  part,  both  in  secretion  and  nutri- 
tion. 

It  may  not  be  uninteresting  to  you  to  know  the  opinions  upon  the 
nature  of  inflammation  held  by  Boerhaave,  Vacca,  Hoffman,  Cullen, 
and  Hunter,  men  who  immortalized  themselves  by  their  genius  and 
research. 

The  first  theory  advanced  was  that  the  capillary  vessels  became 
obstructed,  whilst  the  vis  a  tergo  remained  the  same,  and  that  it 
might  depend  upon  the  following  causes :  1.  Morbid  lentor  of  the 


LECTURE    II.  —  INFLAMMATION.  37 

blood ;  2.  Error  loci  of  the  globules ;  3.  Spasm  of  the  extreme  ves- 
sels. It  is  now,  however,  well  known  that  the  blood  is  not  more 
viscid,  and  that  it  coagulates  more  slowly  in  inflammation  than  in 
a  state  of  perfect  health.  The  free  communication  by  anastomosis 
would  prevent  any  serious  disturbance  resulting  from  misplaced 
globules.  Vacca  thought  that  a  debility  of  the  capillary  vessels 
would  produce  all  the  symptoms  that  are  presented,  even  in  cases  of 
an  aggravated  character. 

John  Hunter  believed  that  the  action  of  the  vessels  was  increased, 
in  which  he  was  unquestionably  correct,  for  they  are  not  only  in- 
creased but  altered. 

The  first  link  in  the  chain  of  this  complicated  process  is  the  im- 
pression made  on  the  nerves  by  which  the  part  is  supplied.  Ubi 
irritatio  ibifluxus  is  an  old  and  true  adage.  The  part  being  irritated, 
an  increased  quantity  of  blood  is  thrown  into  the  vessels,  which 
enlarge,  and  the  circulation  continues  to  increase  until  they  become 
so  distended  that  they  lose  all  control  over  their  contents,  and  finally 
become  entirely  obstructed.  The  white  globules  are  thought  to  per- 
form a  very  active  part  in  producing  this  result.  They  are  more 
adhesive,  move  more  slowly,  are  larger  than  the  red  globules,  and, 
no  doubt,  are  mainly  instrumental  in  rendering  the  vessels  impervi- 
ous. When  the  blood  ceases  to  circulate  through  the  vessels,  disor- 
ganization commences.  Fatty  degeneration,  indicated  by  the  presence 
of  oil-globules,  is  then  observed,  and  very  soon  the  coagulable  lymph 
previously  effused  is  converted  into  pus ;  the  surrounding  parts,  by 
the  pressure  it  exerts,  are  absorbed  to  make  room  for  its  accommo- 
dation, and  an  abscess  is  produced,  which  is  only  one  of  the  results 
of  inflammation. 

The  remainder,  with  the  terminations,  will  be  considered  in  a  sub- 
sequent lecture. 


38  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE    III. 

GENTLEMEN  :  In  my  last  lecture  I  endeavored  to  describe  the 
causes,  nature,  and  symptoms  of  inflammation ;  to-day  I  will  enu- 
merate the  remedies  by  which  it  may  either  be  prevented  or  con- 
trolled. 

It  is  always  better  to  prevent  a  disease  than  to  cure  it  after  it  has 
supervened.  The  preventive  treatment  will  first  be  considered. 

Should  a  foreign  body,  as  a  piece  of  metal,  be  imbedded  in  the 
cornea  or  sclerotic  membranes,  or  find  its  way  between  the  lids  and 
conjunctiva,  if  allowed  to  remain,  inflammation  must  result.  The 
first  indication,  therefore,  is  to  remove  the  cause,  and  generally  the 
effect  will  subside. 

Should  there  be  drawn  into  the  trachea  by  a  violent  inspiratory 
effort  a  button  or  other  substance,  which  can  neither  be  dissolved  nor 
softened  by  the  humidity  and  warmth  naturally  existing  in  all  the 
internal  cavities,  if  it  is  allowed  to  remain,  violent  inflammation  must 
result,  and  death  from  either  acute  inflammation  or  disorganization 
of  the  mucous  membrane  necessarily  occurs. 

The  same  consequences  should  be  expected  from  the  presence  of  a 
foreign  body  in  the  urinary  or  gall  bladder,  and  a  similar  treatment 
is  indicated.  Besides  removing  the  cause  it  sometimes  becomes 
necessary  to  prescribe  rest,  low  diet,  laxatives,  anodynes,  and  espe- 
cially cold  applications.  After  severe  injuries  they  are  all  indispen- 
sably necessary.  Sometimes  it  is  sufficient  to  apply  lint  wet  with 
cold  water,  which  should  be  frequently  renewed.  In  injuries  of  a 
more  severe  character,  however,  it  becomes  necessary  to  apply  cold 
water  constantly,  and  if  that  is  riot  sufficient  to  prevent  or  subdue 
the  increased  arterial  action,  then  ice  may  be  added.  It  is  seldom 
that  an  injury  is  so  violent,  or  the  tendency  to  increased  arterial 
action  resulting  from  it  so  great,  as  to  resist  the  application  even  of 
cold  water  without  the  addition  of  either  ice  or  other  substances 
calculated  to  diminish  the  temperature ;  in  proof  of  which  I  will 
mention  two  cases  that  have  occurred  recently  in  this  city.  The 
first  officer  of  the  Oakland  ferry-boat  had  his  foot  caught  near  the 


LECTURE    III.  —  REMEDIES    FOR    INFLAMMATION.  39 

centre  in  a  coil  of  the  hawser,  and  it  was  torn  off.  The  integument 
and  bones  yielded  readily,  but  the  tendons  were  torn  out  with  more 
or  less  of  the  muscular  tissue  with  which  they  were  connected, 
and  it  is  needless  for  me  to  say  that  such  an  injury  was  exceed- 
ingly severe.  Being  sent  to  my  private  hospital,  beside  the  use  of 
anodynes,  rest,  and  laxatives,  the  limb  was  placed  in  an  easy  posi- 
tion, and  kept  cool  by  the  frequent  application  of  water.  In  ten 
days  not  the  slightest  inflammation  existed,  and  not  a  particle  of  pus 
had  been  secreted.  Poultices  were  then  applied,  and  in  four  or  five 
days  granulations  appeared,  the  stump  began  to  suppurate,  and  the 
spiculaB  of  bone,  which  rendered  the  surface  of  the  wound  irregular, 
were  then  removed. 

In  six  weeks  after  the  occurrence  of  the  accident,  which  it  was 
supposed  would  result  at  least  in  a  loss  of  the  limb,  he  walked  into 
my  office  with  a  boot  on  what  remained  of  his  foot,  and  was  scarcely 
lame. 

Case  2d.  One  of  our  United  States  Senators  was  thrown  from  a 
buggy,  and  the  tibia  of  the  right  leg  was  fractured  above  the  ankle. 
The  fibula  was  dislocated,  and  the  extremity  protruded  through  a 
wound  at  least  three  inches  in  length.  Several  physicians  being 
present,  immediate  amputation  was  urged.  Guided  by  former  ex- 
perience, I  determined  to  make  an  effort  to  save  the  limb.  The 
dislocation  was  reduced  and  the  leg  placed  upon  Roe's  double  in- 
clined plane,  which  had  been  well  padded  with  cotton,  for  the  pur- 
pose of  preventing  unequal  pressure  and  subsequent  ulceration. 
Cold  irrigation  was  kept  up  for  ten  days,  and  the  sulphate  of  mor- 
phia administered  to  relieve  pain.  At  the  expiration  of  that  time 
the  water  dressing  was  substituted.  In  forty  days  the  wound  had 
healed,  the  motion  of  the  joint  was  preserved,  and  he  was  able  to 
visit  Sacramento  to  conduct  a  law  case  before  the  Supreme  Court  of 
the  State.  He  now  experiences  no  inconvenience  from  the  injury. 
Cold  water  was  applied  until  the  time  for  inflammation  to  occur  had 
passed.  Then  the  water  dressing  was  substituted  for  the  purpose  of 
promoting  the  granulation  and  cicatrization  of  the  wound. 

Other  cases  might  be  adduced,  but  these  are  all  that  I  consider 
necessary  to  establish  the  beneficial  influence  of  cold  irrigation  as  a 
preventive  of  inflammation  after  violent  injuries. 

The  great  desideratum  in  the  treatment  of  inflammation  is  to  cause 


40  LECTURES    ON    PRACTICAL    SURGERY. 

it  to  terminate  by  resolution,  or  without  leaving  any  change  either  in 
the  structure  or  appearance  of  the  part  inflamed. 

The  first  thing  to  be  taken  into  consideration  is  the  cause.  When 
that  cannot  be  removed,  or  its  removal  does  not  give  relief,  then 
other  remedies  must  be  applied,  the  most  prompt,  powerful,  and 
efficient  of  which  is  the  abstraction  of  blood.  Bloodletting  may  be 
either  general  or  local.  Formerly  a  great  deal  more  blood  was 
drawn  in  acute  inflammation  than  at  present,  which  can  only  be  ex- 
plained by  taking  into  consideration  the  fact  that  physicians  had 
then  no  other  means  by  which  the  action  of  the  heart  could  be  con- 
trolled. 

Then  bloodletting  may  have  been  too  frequently  resorted  to,  but 
now  I  am  satisfied  that  the  use  of  the  lancet  is  too  much  neglected. 
I  believe  that  many  patients  have  died  who  might  have  been  re- 
lieved by  bloodletting ;  and  those  who  escaped  death  are  left  with 
some  organic  disease  which  would  not  have  existed  if  the  inflam- 
mation had  been  controlled  by  bloodletting  before  organic  lesions 
resulted. 

I  have  always  been  an  advocate  of  the  lancet.  Formerly  I  bled, 
it  is  true,  more  than  at  present,  because  it  was  then  necessary  to  rely 
almost  if  not  entirely  upon  the  lancet ;  but  now  we  have  other  means 
by  which  arterial  action  can  be  controlled  more  effectually.  Still  these 
remedies  do  not  relieve  the  capillary  vessels  so  completely  as  vene- 
section. 

Nearly  all  writers  caution  us  against  bleeding  children,  women, 
and  old  people.  I  am,  however,  satisfied  that  so  far  as  women  and 
children  are  concerned  there  is  no  danger.  I  have  bled  children  at 
all  ages,  and  a  month  has  not  elapsed  since  I  took  eight  ounces  of 
blood  from  a  child  six  months  old  who  had  convulsions  produced 
by  ligating  a  large  nsevus  on  the  neck.  The  child  was  relieved, 
and  convalesced  as  rapidly  as  any  I  have  ever  treated.  I  always 
bleed  children  in  convulsions  when  they  occur  during  the  acute 
stage  of  disease,  because  bloodletting  relieves  the  capillaries  of  the 
brain,  and  prevents  the  consequences  which  might  otherwise  result. 

When  inflammation  is  accompanied  by  fever  of  a  sthenic  charac- 
ter, with  a  full,  strong,  and  frequent  pulse,  together  with  increased 
heat,  thirst,  and  indeed,  with  all  the  symptoms  resulting  from  in- 
creased arterial  action,  then  the  lancet  should  be  used. 

It  is  important  when  you  resort  to  venesection  that  the  greatest 


LECTURE    III.  —  BLOODLETTING.  41 

possible  effect  should  be  produced  by  letting  the  smallest  quantity 
of  blood.  It  is  easy  to  remove  blood  but  very  difficult  to  restore  it. 
Even  if  the  patient  be  strong  and  vigorous,  it  is  desirable  that  this 
rule  should  be  observed ;  for  that  reason  you  should  always  place 
the  patient  in  a  semi-erect  position,  and  open  a  large  vein  to  allow 
the  blood  to  flow  in  a  full  stream  This  will  produce  the  desired 
effect  more  certainly  and  speedily  than  if  the  blood  should  flow  with 
less  rapidity.  You  are  advised  by  all  writers  to  open  the  median 
basilic  in  preference  to  any  other  vein.  That  is  directly  over  the 
brachial  artery,  and  I  think  it  is  much  better  to  open  a  vein  on  the 
radial  side  of  the  tendon  of  the  biceps.  There  you  can  do  no  harm, 
and  serious  consequences  might  result  from  opening  the  vein  usually 
selected.  I  always  feel  for  the  artery,  and  open  a  vein  which  does 
not  lie  directly  over  it,  otherwise  you  subject  the  patient  to  the 
danger  resulting  from  a  varicose  aneurism.  What  effect  should  you 
expect  from  venesection  ?  The  pulse  becomes  more  feeble  and  less 
frequent,  the  face  becomes  pale,  sickness  is  usually  complained  of, 
and  if  the  patient  is  not  speedily  placed  in  a  recumbent  position, 
syncope  will  ensue.  That  should,  if  possible,  be  avoided,  because 
when  it  follows  the  abstraction  of  blood  the  reaction  is  usually  very 
violent,  and  if  proper  precautions  are  not  taken  it  might  prove  fatal. 
You  should,  therefore,  so  soon  as  sickness  occurs,  and  the  face  be- 
comes pale,  and  perspiration  appears  on  the  forehead,  remove  the 
pillows,  and  place  the  patient  in  a  recumbent  position.  Sprinkle 
the  face  with  cold  water,  and  very  soon  the  faintness  will  disappear. 

Bloodletting  not  only  subdues  or  controls  acute  inflammation,  but 
also  prevents  congestion  and  chronic  inflammation  of  the  organ  af- 
fected, which  results  in  many  cases  where  such  means  are  neglected. 

In  some  cases  bloodletting  can  be  dispensed  with,  but  in  others  it 
is  indispensable,  as  in  gonorrhoeal,  purulent,  or  acute  ophthalmia;  it 
is  impossible  to  control  the  disease  by  the  ordinary  remedies,  and  as 
disorganization  frequently  occurs  in  twenty-four  hours,  the  most 
prompt  and  energetic  treatment  should  be  adopted.  Why  do  you 
see  so  many  blind  persons  in  the  streets  of  every  city  ?  Because 
acute  inflammation  of  this  organ  is  frequently  treated  by  the  appli- 
cation of  poultices,  alum  curd,  and  other  remedies  equally  inefficient, 
until  the  cornea  ulcerates,  the  humors  escape,  and  the  disease  has 
passed  beyond  the  reach  of  the  most  skilful  treatment.  The  cases 
in  which  bloodletting  is  especially  required  will  be  specified  when 


42  LECTURES  ON  PRACTICAL  SURGERY. 

the  diseases  of  the  various  tissues  and  organs  of  the  body  are  con- 
sidered. 

Bloodletting  includes  venesection  or  the  opening  of  a  vein,  and 
arteriotomy  or  the  division  of  an  artery.  There  is  but  one  artery 
that  it  is  ever  necessary  or  proper  to  open,  and  that  is  the  temporal. 
In  cases  of  acute  ophthalmia,  I  frequently  divide  the  anterior 
branches  of  that  artery  instead  of  resorting  to  venesection.  In 
inflammation  of  the  brain,  after  venesection,  arteriotomy  should  be 
performed,  and  if  the  haemorrhage  be  troublesome  or  an  aneurism 
forms,  then  the  vessel  should  be  divided  transversely,  and  the  bleed- 
ing arrested  by  the  application  of  a  compress  and  bandage.  Local 
bleeding  includes  cupping,  leeching,  puiictures,  and  incisions.  All 
these  methods  of  abstracting  blood  are  sometimes  exceedingly  useful. 
When  any  of  the  abdominal  organs  are  inflamed,  leeching  should 
be  performed,  because  it  is  less  powerful  than  cupping  and  equally  as 
efficient;  but  in  pulmonary  inflammation,  cups  are  preferable,  not 
only  because  as  much  blood  can  be  abstracted  as  may  be  necessary, 
but  also  in  consequence  of  the  great  benefit  derived  from  the  coun- 
ter-irritation inseparable  from  their  application. 

Punctures  are  frequently  resorted  to  for  the  purpose  of  removing 
blood  locally,  and  particularly  in  orchitis,  and  is  especially  necessary 
when  the  inflammation  is  accompanied  by  an  effusion  between  the 
testicle  and  tunica  vaginalis.  You  not  only  abstract  blood  but  re- 
move the  pain  resulting  from  the  pressure  produced  by  the  presence 
of  serum. 

It  is  seldom  necessary  to  apply  leeches  to  the  scrotum,  since  any 
quantity  of  blood  can  be  removed  by  puncture,  which  is  more  expe- 
ditious and  less  expensive  than  leeching.  Punctures  are  useful  in 
other  cases.  Suppose,  for  example,  the  hand  be  violently  and  ex- 
tensively inflamed  as  the  result  of  an  injury.  Instead  of  opening  a 
vein,  numerous  punctures  should  be  made  in  the  direction  of  the 
limb,  avoiding  the  large  veins ;  this  will  relieve  the  capillaries  more 
effectually  and  speedily  than  could  be  done  by  the  application  of 
leeches. 

Incisions  are  useful  and  indeed  indispensable  in  periostitis.  If 
this  be  neglected  when  the  bones  of  the  hand  are  diseased,  the  in- 
flammation frequently  extends  up  the  arm  in  the  direction  of  the 
tendons,  implicating  the  surrounding  cellular  tissue,  and  cannot  be 
arrested  by  any  other  treatment.  Whenever  the  periosteum  is  in- 


LECTURE    III.  —  CATHARTICS.  43 

flamed,  no  matter  whether  the  bone  it  covers  be  small  or  large,  a 
free  incision  should  be  made,  and  if  practiced  before  it  is  detached 
and  the  bone  denuded,  immediate  relief  will  be  afforded.  Although 
bloodletting  is  very  important  in  the  treatment  of  inflammation,  you 
must  not  suppose  that  either  it  or  all  the  other  remedies  which  will 
be  hereafter  enumerated  will  be  required  in  every  case  of  inflam- 
mation, as  it  very  frequently  will  disappear  under  the  influence  of 
rest,  cathartics,  and  cold  applications. 

The  next  class  of  remedies  to  which  I  shall  allude  is  cathartics ; 
first  to  those  which  simply  evacuate  the  intestinal  canal,  which  is 
exceedingly  important  in  the  management  of  every  case.  They  are 
called  laxatives,  and  include  ext.  juglandis,  ol.  ricini,  rhubarb,  aloes, 
ox-gall,  etc.  The  latter  removes  the  contents  of  the  alimentary 
canal  more  effectually  probably  than  any  of  those  enumerated,  with- 
out producing  either  much  pain  or  inconvenience  by  its  action. 

2d.  When  it  is  desirable  to  increase  the  serous  secretion  of  the  in- 
testinal mucous  membrane,  as  in  dysentery  accompanied  with  fever, 
and  the  discharge  of  mucus  with  indurated  and  offensive  fecal 
matter,  then  citrate  of  magnesia,  Epsom  salts,  and  saline  cathartics 
generally,  or  the  latter  combined  with  senna,  will  be  found  most 
useful. 

3d.  When  it  becomes  necessary  to  increase  or  change  the  secretion, 
either  of  the  liver  or  other  abdominal  organs,  which  will  be  fre- 
quently required  in  malarious  districts  of  country,  the  most  useful  for 
that  purpose  are  blue  mass,  hyd.  cum  creta,  calomel,  fluid  ext.  sennse, 
and  above  all  the  ext.  juglandis,  as  cathartics.  The  last  named  has 
been  too  much  neglected,  for  if  taken  in  a  dose  of  twenty  grains  at 
night,  it  will  produce  two  or  three  bilious  discharges  in  the  morning; 
and  in  combination  with  aloes,  it  is  the  only  laxative  I  employ,  ex- 
cept the  fluid  ext.  senna?  in  constipation  accompanying  indigestion. 

4th.  They  act  by  revulsion,  and  are  exceedingly  important  in  the 
treatment  of  ascites,  and  particularly  in  acute  affections  of  the  supra- 
diaphragmatic  organs.  They  act  on  the  principle  of  revulsion  or 
counter-irritation.  Of  this  class,  the  following  are  the  most  useful : 
comp.  ext.  colocynth,  in  large  doses,  ol.  tiglii,  scammony,  gamboge, 
podophyllin,  saline  cathartics,  and  above  all  the  ext.  elaterii  comp. 
This  should  be  given  in  doses  of  one-quarter  of  a  grain  every  two 
hours  until  a  decided  effect  is  produced.  It  increases  the  serous 
secretion  of  the  alimentary  canal  more  than  any  other  article  of  the 


44  LECTURES  ON  PRACTICAL  SURGERY. 

Materia  Medica,  and  consequently  is  the  most  powerful  revulsive 
and  counter-irritant. 

Emetics  are  seldom  used  in  inflammation,  being  generally  inappli- 
cable except  in  affections  of  the  throat,  lungs,  and  testicles.  In  sur- 
gery they  are  seldom  prescribed  unless  it  be  in  orchitis,  and  in  that 
difficulty  they  are  invaluable.  Depressants  diminish  the  action  of 
the  heart  and  increase  the  secretions,  and  consequently,  are  exceed- 
ingly valuable  in  the  treatment  of  inflammation. 

The  most  active  and  reliable  are : 

1.  Fluid  ext.  veratrum  viride. 

2.  Tinct.  aconiti  rad. 

3.  Antimon.  tartarizatum. 

4.  Rad.  ipecacuanha. 

5.  Pot.  nitrate. 

Physicians  differ  in  opinion  in  reference  to  the  relative  value  of 
depressants.  Professor  Gross  thinks  that  tartar  emetic  stands  at  the 
head  of  the  remedies  known  to  exert  that  influence.  I  am  sorry  to 
differ  with  so  eminent  a  Burgeon  upon  any  subject,  but  I  think 
really  that  there  is  no  comparison  between  that  remedy  and  either 
veratrum  or  aconite.  Without  distressing  nausea,  the  effect  of  tartar 
emetic  is  uncertain,  but  the  veratrum,  even  in  moderate  doses,  never 
disappoints.  I  believe  that  the  nitrate  of  potash  and  aconite  are  both 
very  useful  as  general  remedies,  there  being  few  who  are  willing  to 
submit  for  an  indefinite  period  to  the  nausea  resulting  from  the  use 
of  either  ipecac  or  tartar  emetic.  Should  sickness  of  the  stomach 
result  from  large  doses  of  the  veratrum  viride,  it,  with  the  prostrat- 
ing effect  of  the  remedy,  will  yield  readily  to  the  action  of  any  alco- 
holic stimulant.  We  should  not  rely,  however,  upon  any  one  arti- 
cle of  the  Materia  Medica  in  the  treatment  of  diseases  so  violent  as 
to  require  the  use  of  powerful  depressants.  The  effect  can  be  in- 
creased and  rendered  more  certain  by  a  combination  of  these  reme- 
dies. The  following  is  the  most  powerful,  and  at  the  same  time 
the  most  generally  applicable  I  have  ever  administered : 

R.— Pot.  Nitrat ^iij. 

Tinct.  Aconiti  Had., 

Ext.  Yerat.  Virid.,          .         .         .         .31. 
Syr.  Scillse, 

"        "        Conipositi,  aa  J|ij. 

M.  Give  one  teaspoonful  every  two  hours. 


LECTURE    III.  —  DIAPHORETICS.  45 

This  will  almost  always  control  the  most  violent  arterial  action 
within  six  hours.  The  pulse  becomes  slow,  the  respiration  natural,  and 
the  temperature  diminished;  and  it  is  probably  the  most  valuable 
adjuvant  to  bloodletting  that  can  be  administered.  When  it  becomes 
necessary  to  relieve  pain,  it  is  much  better  to  administer  the  anodyne 
separately,  and  as  occasion  may  require,  than  to  combine  it  with  this 
or  any  other  combination  of  depressants. 

Diaphoretics,  to  use  the  language  of  Professor  Gross,  bear  the 
same  relation  to  the  skin  that  cathartics  do  to  the  bowels.  The 
amount  of  fluid  secreted  by  the  skin  is  from  twelve  to  sixteen  ounces 
daily,  which  shows  the  necessity  of  attending  particularly  to  this  im- 
portant emunctory  in  the  treatment  of  every  disease.  Of  this  class 
of  remedies  only  a  few  are  decidedly  useful. 

1.  Ant.  tart, 

2.  R.  ipecac.          ^ 

3.  Spts.  mindereri. 

4.  Dover's  powder  and  other  combinations  with  opium. 

5.  Cold  water. 

6.  Warm  drinks. 

7.  Steam  and  hot  bottles. 

Tartar  emetic  is  certainly  one  of  the  most  valuable  diaphoretics, 
and  in  combination  with  opium,  its  effect  upon  the  skin  is  more 
certain  than  when  administered  alone.  The  next  in  importance  as  a 
diaphoretic  is  ipecac.  It  is  very  useful,  particularly  in  diseases  of 
children,  either  alone  or  when  combined  with  opium  in  the  com- 
pound known  as  Dover's  powder.  I  prefer  to  Dover's  powder  for 
adults  a  combination  of  opium,  ipecac,  and  aloes.  It  can  be  admin- 
istered in  pills.  It  is  less  unpleasant  to  the  taste,  is  not  so  liable  to 
nauseate,  and  does  not  produce  constipation  ;  e.  #., 

R. — Gum  Opii, 

Pulv.  Had.  Ipecac., 

Gum.  Aloes  S.,  aa  .        • gr.  x. 

M.  Fiat  pil.  No.  xx. 

Two  may  be  given  at  night,  or  one  three  or  four  times  a  day,  as 
may  be  required,  either  to  relieve  pain  or  act  as  a  diaphoretic. 
Spts.  of  mindererus  or  liquor  am.  acetatis  is  an  exceedingly  valuable 
stimulating  diaphoretic  in  asthenic  forms  of  fever,  whether  traumatic 
or  idiopathic.  In  typhoid  fever,  a  tablespoonful,  in  combination 


46  LECTURES    ON    PRACTICAL    SURGERY. 

with  five  drops  of  the  tinct.  of  nux  vomica  every  three  hours,  is 
one  of  the  most  valuable  remedies  that  can  be  prescribed.  It  should 
be  in  such  cases  continued  so  long  as  diaphoretics  and  tonics  are 
required. 

The  next  diaphoretic  to  which  I  will  call  your  attention  is  cold 
water.  Very  frequently  a  free  draught  of  cold  water  will  act 
promptly  and  effectually  as  a  diaphoretic.  In  fever  resulting  from 
cold,  if  the  patient  is  put  to  bed,  covered  with  blankets,  and  allowed 
to  drink  freely  of  ice-water,  very  frequently  the  skin  becomes  moist, 
the  fever  will  subside,  and  the  effect  will  be  equal  to  that  produced 
by  warm  drinks,  and  much  more  agreeable  to  the  patient. 

We  are  all  familiar  wjth  the  effect  of  hot  drinks  if  administered 
when  the  patient  is  covered  warmly  in  bed;  their  action  is  greatly 
increased  by  the  assistance  of  steam,  which  may  be  obtained  and 
applied  by  covering  with  heavy  blankets  a  patient  who  is  placed  on 
a  cane-seat  chair  over  a  tub  of  hot  water.  I  have  frequently  in 
intermittent  fever  prevented  a  paroxysm,  by  surrounding  a  patient, 
an  hour  before  its  expected  advent,  with  a  dozen  ears  of  Indian  corn 
taken  from  boiling  water.  The  steam  arising  from  the  corn  produces 
perspiration  speedily  and  abundantly,  and  it  is  preferable  to  anything 
else  that  can  be  employed  for  that  purpose. 

Both  hot  drinks  and  external  heat  are  exceedingly  valuable  when 
either  the  extremities  are  cold,  or  there  is  a  deficiency  of  arterial 
action. 

Diuretics  are  administered  to  restore  or  increase  the  urinary  secre- 
tion. They  are  a  very  important  class  of  remedies.  They  act  differ- 
ently upon  the  urinary  organs,  and  are  not  all  applicable  to  the  same 
cases. 

Squills,  colchicum,  and  digitalis  increase  the  urinary  secretion, 
and  promote  the  absorption  of  serum,  effused  either  in  the  cavi- 
ties or  cellular  tissue ;  consequently  they  are  indispensable  in  the 
treatment  of  dropsy,  especially  if  it  depend  on  disease  of  the  heart. 
In  doses  of  ten  drops  every  three  hours,  the  tinct.  of  digitalis,  com- 
bined with  nitrate  of  pot.  and  syr.  scillse,  will  remove  a  dropsical  effu- 
sion speedily,  unless  it  should  result  from  organic  disease  of  the  liver 
or  kidneys,  and  then  all  remedies  fail. 

The  nitrate,  acetate,  carbonate,  and  bitartrate  of  potassa,  restore 
the  secretion  of  urine,  increase  its  quantity,  and  frequently  allay 
irritation  of  the  urinary  organs.  They  are,  however,  inferior  in  that 


LECTURE    III.  —  ANODYNES.  47 

respect  to  copaiba,  cubebs,  buchu,  and  uva  ursi.  They  increase  the 
secretion  to  some  extent,  and  at  the  same  time  allay  irritation  of  the 
mucous  membrane  of  the  bladder  and  urethra,  and  when  the  diseases 
to  which  these  remedies  are  applicable  shall  be  under  consideration, 
the  mode  of  administration  and  the  peculiarities  of  their  action  will 
be  specified. 

Anodynes. — The  success  of  the  surgeon  depends  more  upon  a 
knowledge  of  the  virtue  of  this  class  of  remedies  than  upon  every- 
thing else  combined.  They  should  follow  depletion,  and  be  given 
in  doses  sufficiently  large  to  produce  the  desired  effect.  Indeed,  a 
patient  should  not  be  allowed  to  pass  a  restless  night.  He  can  be 
rendered  quiet  and  relieved  of  pain,  even  if  sleep  cannot  be  produced, 
by  the  administration  of  a  suitable  dose  of  opium  or  some  of  its 
preparations.  Four  grains  of  opium  or  one  grain  of  morphine  may 
be  given  with  perfect  safety  in  twenty-four  hours.  One  of  the  best 
preparations  of  opium  is  McMunn's  elixir,  in  doses  of  from  twenty 
to  thirty  drops.  It  does  not  constipate  the  bowels  as  much  as  the 
other  preparations,  and  is  applicable  to  every  case  in  which  opiates 
are  indicated.  In  cases  of  idiosyncrasy  in  which  it  is  impossible  to 
take  opium  without  inconvenience,  I  have  found  codeia  superior  to 
any  other  narcotic.  It  is  prepared  from  the  poppy,  and  is  objection- 
able only  on  account  of  its  cost. 

If  codeia  cannot  be  obtained,  or  fails  to  produce  the  desired  effect, 
give  hyd.  of  chloral,  and  should  that  fail,  the  endermic  or  hypo- 
dermic effect  of  morphine  should  be  secured.  Morphine  may  be 
applied  in  one-grain  doses  to  a  denuded  surface,  or  a  solution  may 
be  thrown  into  the  subcutaneous  cellular  tissue,  with  the  most  happy 
result ;  and  in  cases  of  idiosyncrasy,  the  unpleasant  effect  when  taken 
into  the  stomach  is  not  experienced.  The  cuticle  may  be  removed 
in  a  few  minutes  by  the  application  of  ammonia,  and  the  effect  of 
the  morphine  is  secured  as  speedily  and  satisfactorily  as  if  no  such 
peculiarity  existed. 

Aconite,  cannabis  indica,  hyoscyamus,  lupulin,  and  other  arti- 
cles have  been  substituted  for  opium,  but  I  have  always  been  dis- 
appointed in  their  effect,  and  I  now  seldom  prescribe  them  as 
narcotics. 


48  LECTURES  ON  PRACTICAL  SURGERY. 


LECTURE    IV. 

GENTLEMEN  :  In  my  last  lecture  I  mentioned  calomel  only  as  a 
useful  cathartic,  but  it  deserves  separate  consideration  in  consequence 
of  its  extraordinary  efficacy  in  inflammation,  particularly  when  the 
violence  of  the  disease  has  been  diminished  by  the  remedies  which 
have  already  been  enumerated. 

In  acute  inflammation,  after  local  and  general  bleeding,  should 
they  be  considered  necessary,  and  the  exhibition  of  an  active  cathar- 
tic, of  which  calomel  may  be  one  of  the  ingredients,  and  the  use 
of  the  combination  of  depressants  already  given,  should  the  inflam- 
mation still  continue,  then  I  advise  you  to  resort  to  calomel.  It 
is  impossible  to  determine  its  modus  operandi,  but  it  is  well  known 
that  it  exerts  a  more  powerful  influence  over  local  inflammation  than 
all  other  remedies  combined,  particularly  when  administered  with 
opium  in  a  sufficient  quantity  to  relieve  pain  until  its  effect  can  be 
obtained,  and  together  with  the  depressants  previously  enumerated 
when  increased  arterial  action  exists. 

In  pneumonia  the  following  prescription  is  superior  to  anything  I 
have  ever  prescribed : 

H.  — Hyd.  Submur  , 

Gum.  Opii,  aa  .         .         .         .     gr.  viij. 

Ext.  Aconiti  Rad.,         .         .         .         .     gr.  xij. 

Ant.  Tart., gr.  ij. 

M.  Fiat  pil.  No    xvi.     Sig.  Give  one  pill  every  three  hours. 

This  combination,  when  alternated  with  the  extract  of  veratrum 
viride,  controls  increased  arterial  action,  allays  irritation,  checks  the 
cough,  which  is  always  distressing,  and  moreover  exerts  a  decided 
influence  over  the  local  difficulty.  The  same  treatment  will  be  found 
extremely  valuable  in  pericarditis,  which,  if  not  speedily  controlled, 
will  result  in  effusion,  and  which,  if  not  properly  treated,  may  ter- 
minate fatally. 

In  acute  ophthalmia,  when  so  violent  as  to  produce  disorganiza- 
tion, there  is  no  substitute  for  this.  If  the  pain  be  violent,  combine 


LECTURE    IV.  —  DIET.  49 

it  with  opium.  If  the  arterial  action  be  increased  give  at  the  same 
time  the  veratrum  viride  and  aconite.  The  veratrum  cannot  be  com- 
bined with  it,  but  may  be  administered  separately  and  alternately. 
Norwood's  and  Thayer's  fluid  extract  are  both  reliable.  Two  drops 
every  two  or  three  hours,  combined  with  the  articles  previously 
mentioned,  will  in  six  or  eight  hours  reduce  the  pulse  to  its  natural 
standard.  The  only  unpleasant  effect  that  should  be  apprehended 
is  distressing  nausea  or  a  sense  of  constriction  of  the  pharynx,  which 
is  more  unpleasant  than  dangerous,  and  yields  readily  to  a  glass  of 
brandy  or  any  other  alcoholic  stimulant.  When  that  symptom  ap- 
pears the  dose  should  be  diminished.  Calomel  unquestionably  is  a 
powerful  remedy  and  should  be  cautiously  prescribed,  since  nothing 
is  more  injurious  to  a  young  physician  than  to  salivate  patients  badly, 
as  neither  they  nor  their  friends  understand  the  necessity  for  such 
treatment,  and  the  physician  may  in  consequence  become  exceedingly 
but  not  always  deservedly  unpopular. 

When  its  administration  becomes  necessary,  always  watch  the 
case  closely ;  examine  the  mouth  at  least  twice  every  day  and  par- 
ticularly the  breath,  for  that  frequently  emits  the  mercurial  odor 
before  the  gums  become  affected.  A  copperish  taste  is  sometimes 
complained  of  before  tumefaction  of  the  mucous  membrane  occurs, 
or  the  action  of  the  salivary  glands  is  increased. 

When  this  result  is  attained,  the  remedy,  having  accomplished  all 
that  can  be  expected,  should  be  abandoned. 

Regimen. — In  the  treatment  of  acute  inflammation,  a  proper  regi- 
men is  indispensable.  The  lowest  diet  that  can  be  prescribed  is 
arrowroot,  which  is,  however,  often  given  to  children  who  require 
the  most  nutritious  food.  In  such  cases,  when  its  use  has  been  con- 
tinued for  three  or  four  weeks,  the  patient  becomes  so  pale  as  to  be 
almost  transparent,  and  is  so  much  enfeebled  as  to  be  unable  to 
resist  the  violence  of  acute  disease. 

There  are  other  articles  that  are  equally  simple  but  much  more 
nutritious,  such  as  sago,  tapioca,  as  well  as  gum  arabic,  barley, 
rice,  and  toast-water.  They  may  be  prescribed  in  any  case,  even 
when  ordinary  nutriment  cannot  be  retained. 

In  acute  inflammation  but  little  nourishment  should  be  taken. 
This  regimen  should  not,  however,  be  continued  too  long.  So  soon 
as  the  appetite  returns  something  more  nutritious  should  be  allowed, 
which  will  be  mentioned  when  chronic  inflammation  is  considered. 

4 


50  LECTURES  ON  PRACTICAL  SURGERY. 

In  such  cases  change  of  position  is  exceedingly  important,  and 
should  be  as  frequent  as  may  be  compatible  with  the  comfort  of  the 
patient. 

Local  Treatment. — The  first  and  most  important  indication  is  to 
remove  the  cause.  If  an  eye  be  inflamed  the  light  should  be  care- 
fully excluded.  If  a  joint  be  injured  it  should  be  kept  at  rest,  as 
anchylosis  frequently  results  from  injuries  in  consequence  of  that 
precaution  being  neglected. 

Local  Bloodletting. — The  next  remedy  in  importance  is  local  blood- 
letting, which  may  be  accomplished  either  by  scarifying,  puncturing, 
leeching  or  cupping.  The  method  to  be  adopted  should  depend  on 
the  position  of  the  part  affected. 

In  orchitis  I  prefer  puncturing.  Never  apply  an  irritant  to  an  in- 
flamed surface,  as  ulceration  may  be  produced  or  the  character  of  the 
inflammation  may  be  changed.  Cups  should  not  be  applied  to  a 
part  that  is  usually  exposed.  If  it  be  considered  necessary  to  ab- 
stract blood  by  them  from  the  temple,  the  hair  should  be  shaved 
off,  and  the  scarificator  applied  where  the  scars  will  not  be  visible. 
A  leech  leaves  a  permanent  cicatrix ;  therefore,  particularly  in 
females,  never  apply  them  to  the  face,  temples,  or  any  exposed  por- 
tion of  the  body. 

Local  bleeding,  as  before  mentioned,  should  usually  be  preceded 
by  general  bloodletting.  As  the  method  best  adapted  to  particular 
cases  was  considered  in  my  last  lecture,  it  will  not  be  repeated. 

Another  very  important  remedy  iii  inflammation  is  cold  irriga- 
tion; and  it  only  remains  for  me  to  describe  a  simple  method  for  ob- 
taining the  full  effect  of  that  remedy.  A  large-mouthed  bottle  filled 
with  cold  water  in  which  candle-wicking  has  been  placed,  and  so 
arranged  as  to  act  as  a  siphon,  may  be  suspended  over  the  part  in- 
flamed, which  should  be  well  protected  by  porous  cloth  or  lint,  and 
the  water  allowed  to  drop  either  occasionally  or  constantly,  as  may 
be  necessary,  to  remove  the  increased  heat,  pain,  and  redness  that 
may  exist.  The  part  should  be  exposed,  to  favor  evaporation ;  other- 
wise the  effect  will  be  similar  to  that  of  a  poultice,  and  the  object  de- 
feated by  the  exclusion  of  the  atmosphere.  Cold  water  may  be  either 
applied  alone  or  combined  with  alcohol.  Six  parts  of  the  former 
and  one  of  the  latter  should  be  applied  as  before  stated  occasionally, 
or  allowed  to  drop  slowly  upon  the  part  inflamed,  according  to  the 
effect  desired.  The  quantity  may  be  easily  regulated  by  the  size  of 


LECTURE    IV.  —  LOCAL    APPLICATIONS,  51 

the  siphon  employed.  Should  the  inflammation  be  so  violent  that 
some  more  active  application  becomes  necessary  to  reduce  or  dimin- 
ish the  temperature,  then  ice,  or  a  combination  of  salt  and  ice,  may 
be  added  to  the  water. 

In  inflammation  of  the  brain  the  most  convenient  method  of  ob- 
taining the  full  effect  of  this  remedy,  is  to  put  pounded  ice  either 
into  a  bladder  or  gum -elastic  bag,  and  keep  it  constantly  applied 
with  the  intervention  of  a  folded  towel,  until  the  disease  is  either 
controlled  or  is  no  longer  amenable  to  treatment.  The  pulse  can  be 
reduced  both  in  force  and  frequency  by  the  application  of  ice  or  iced 
water  to  the  head  more  speedily  than  by  the  administration  of  the 
depressants  heretofore  mentioned.  When  irrigation  is  not  required, 
I  have  found  the  following  sedative  exceedingly  useful : 

Tinct.  Arnicae,          ........  ^iv. 

Tinct.  Opii, ,         .  ^ij. 

Plumbi  Acetatis,       .  .         .         .         .         .         .  ^ss. 

M.  Sig.  For  external  use,  diluted. 

Put  into  a  quart  of  water  and  apply  by  saturating  three  or  four 
double  of  lint  or  porous  cloth  with  the  mixture ;  and  evaporation  is 
prevented  by  covering  it  closely  with  oiled  silk.  This  application 
should  be  renewed  two  or  three  times  in  twenty-four  hours,  and  con- 
tinued so  long  as  may  be  necessary.  Erichsen  recommends  that  §ij 
of  the  tinct.  of  arnica  be  combined  with  a  pint  of  water,  and  applied, 
either  with  or  without  the  oiled  silk,  as  may  be  considered  most  ad- 
visable under  the  circumstances. 

Fomentations. — Cloths  wrung  out  of  hot  water,  a  decoction  of 
chamomile  flowers,  poppy-heads,  or  hops,  or  bags  containing  the 
articles  mentioned,  when  dipped  in  hot  water  and  applied,  particu- 
larly to  the  chest  and  abdomen,  if  protected  by  oiled  silk  and  se- 
cured by  a  bandage,  will  be  found  exceedingly  useful  in  gastritis, 
peritonitis,  pneumonia,  and  particularly  in  pleurisy. 

Steeping  is  a  variety  of  fomentation  which  is  very  useful  in  some 
cases  of  inflammation,  and  particularly  when  located  upon  the 
face  or  head ;  tow,  lint,  flannel  or  soft  porous  cloth,  should  be  kept 
wet  with  warm  water  and  applied  to  the  part  affected,  so  long  as 
may  be  necessary.  Steam  may  be  applied  to  any  part  of  the  body 
by  a  gutta-percha  tube  attached  to  the  spout  of  a  coffee-pot  or  kettle, 
which  contains  hot  water.  A  very  convenient  method  of  applying 


52  LECTURES  ON  PRACTICAL  SURGERY. 

steam,  either  to  the  eyes  or  ears,  is  by  inverting  a  funnel  over  hot 
water,  and  directing  it  to  the  part  affected,  the  head  being  at  the  same 
time  covered  with  a  towel  to  prevent  the  escape  of  the  vapor.  In  in- 
flammation of  the  ear,  which  is  the  most  painful  variety  of  inflam- 
mation, relief  is  generally  afforded  in  fifteen  or  twenty  minutes ;  but 
should  it  fail,  a  few  drops  of  vin.  opii,  digitalis,  and  glycerin  should 
be  introduced,  and  warm-water  dressing  applied  : 

R  —Vin    Opii, 

Tinct.  Fol.  Digit.,  aa £ij. 

Glycerinse,          ........     giv. 

M.  Sig.  Apply  as  directed. 

The  next  local  remedy  to  which  I  will  refer  is  the  cataplasm  or 
poultice,  which  although  in  many  cases  very  useful,  is  greatly  abused. 
A  poultice  should  never  be  applied  until  suppuration  is  threatened, 
and  then  I  usually  prefer  the  warm-water*  dressing,  introduced  by 
Mr.  William  Liston,  of  England.  When  properly  applied  it  has  the 
same  effect,  is  much  more  convenient,  and  much  less  filthy  and  disa- 
greeable than  poultices.  All  that  is  necessary  to  enable  you  to  ob- 
tain the  full  effect  of  that  remedy,  is  to  apply  to  the  part  affected 
four  or  five  double  of  lint  or  old  porous  cloth  saturated  with  warm 
water,  cover  it  with  oiled  silk,  and  secure  it  by  a  bandage  so  per- 
fectly as  to  prevent  evaporation.  The  virtue  of  every  variety  of 
poultice  depends  on  the  heat  and  moisture  it  contains,  and  the  warm- 
water  dressing  combines  both  as  perfectly  as  any  poultice.  If  the 
lint  be  kept  wet,  and  the  heat  retained,  the  effect  will  be  secured. 

The  warm-water  dressing  or  poultice  should  not  be  continued 
until  the  part  becomes  sodden ;  or,  in  other  words,  until  the  skin 
becomes  thickened  and  irritable,  for  then  it  is  always  decidedly 
injurious.  The  articles  generally  used  for  poultices,  and  which  are 
found  most  useful,  are  corn-meal,  bread  and  milk,  arrowroot,  turnips, 
carrots,  potatoes,  flaxseed  meal,  and  slippery  elm  bark.  With  warm 
water  you  can  make  a  poultice  of  anything  that  will  retain  heat  and 
moisture.  It  should  be  sufficiently  soft  to  be  easily  spread  upon  a 
cloth.  The  flaxseed  and  slippery-elm  poultices  adhere  at  the  edges 
to  the  skin,  and  remain  moist  longer  than  those  made  of  any  other 
substance.  Any  poultice  may,  however,  be  kept  moist  by  covering 
it  with  oiled  silk.  It  was  formerly  believed  that  charcoal  possessed 
extraordinary  efficacy  when  gangrene  was  threatened.  It  is  now 


LECTURE  IV.  —  LOCAL  APPLICATIONS.          53 

seldom  used,  but  if  it  be  indicated,  it  should  be  combined  with  corn- 
meal  and  warm  water  in  such  quantities  as  to  give  it  the  proper 
consistency.  I  do  not  believe  that  it  is  particularly  efficacious,  and 
it  is  objectionable  in  consequence  of  the  difficulty  experienced  in 
removing  it  after  it  has  been  applied. 

Yeast  poultices  are  very  convenient  when  a  tendency  to  gangrene 
exists.  They  should  be  prepared  by  combining  the  yeast  either  with 
ground  flaxseed  or  slippery  elm  bark,  and  should  be  removed  two 
or  three  times  in  twenty-four  hours.  A  very  important  remedy  in 
the  treatment  of  inflammation  is  the  nitrate  of  silver.  Although  I 
do  not  entertain  an  exalted  opinion  of  its  efficacy  in  all  the  diseases 
in  which  it  is  recommended,  yet  in  ophthalmia,  ulcerations  of  the 
throat,  and  other  local  difficulties  it  is  invaluable.  Always  use  the 
stick  to  an  ulcerated  surface,  particularly  when  irritable,  because  the 
pain  is  relieved  by  the  application. 

When  an  ulcer  is  disposed  to  cicatrize,  and  the  granulations  rise 
above  the  surrounding  integument,  the  edges  should  be  touched 
every  alternate  day  with  the  nitrate  of  silver.  I  followed  the 
physician  of  a  public  hospital  in  this  city,  for  a  short  time,  who 
carried  a  stick  of  nitrate  of  silver  in  his  hand,  whilst  making  his 
visits,  and  cauterized  every  ulcer  in  the  wards  of  the  hospital 
whether  above,  below,  or  on  a  level  with  the  integument.  Instead 
of  healing,  they  were  all  soon  converted  into  callous  ulcers,  which 
required  warm  applications  and  pressure  to  enable  them  to  granu- 
late and  cicatrize.  In  herpes,  erythema,  and  erysipelas,  twenty 
grains  of  the  nitrate  of  silver  to  the  ounce  of  distilled  water  is 
frequently  prescribed  as  a  local  remedy,  yet,  even  in  these  affec- 
tions, I  prefer  the  compound  tincture  of  iodine  to  anything  I  have 
ever  employed. 

When  vesication  is  not  desirable,  I  combine  it  with  an  equal 
quantity  of  the  tincture  of  arnica.  It  should  be  applied  with  a 
camel's-hair  pencil  three  or  four  times  a  day,  and  you  will  seldom 
be  disappointed  with  the  effect. 

Iodine  has  been  recommended  in  affections  of  the  eyes  and  throat, 
but  having  no  experience  in  its  use,  I  can  recommend  other  means 
with  more  confidence.  When  applied  to  an  ulcerated  surface,  it 
should  be  only  one-fourth  the  strength  of  the  alcoholic  tincture,  and 
then  it  may  be  applied  either  to  the  eye,  throat,  or  even  to  a  denuded 
surface  without  producing  excessive  pain. 


54  LECTURES    ON    PRACTICAL    SURGERY. 

Destructives  are  employed  to  destroy  the  germ  of  disease,  as  in 
hydrophobia,  malignant  pustule,  and  chancre.  I  have  never,  ex- 
cept in  the  Hotel  Dieu  in  Paris,  seen  a  case  of  malignant  pustule, 
and  there  the  actual  cautery  was  applied  and  its  progress  invariably 
arrested.  In  the  treatment  of  chancre  I  have  had  an  extensive 
experience,  and  now  seldom  apply  any  destructive  except  nitric 
acid.  I  prefer  it  either  to  the  acid  nitrate  of  mercury  or  the  solu- 
tion of  corrosive  sublimate.  It  should  be  applied  with  a  small  piece 
of  wood,  the  size  and  shape  of  an  ordinary  lead-pencil,  and  its  action 
should  be  limited  either  by  the  application  of  water  or  the  super- 
carbonate  of  soda  in  two  or  three  minutes  after  it  has  been  applied, 
according  to  the  greater  or  less  effect  desired. 

Irritable  ulcers,  whether  they  be  simple  or  specific,  when  painful, 
are  relieved  more  speedily  by  the  application  of  nitric  acid  than  by 
any  other  remedy  I  have  ever  employed. 

Counter-irritants  include  rubefacients,  vesicants,  and  suppurants. 
The  first  only  irritate  the  skin,  as  alcohol,  vinegar,  ammonia,  cam- 
phor, and  mustard.  When  a  decided  and  speedy  effect  is  desired, 
mustard  should  be  preferred.  When  mixed  with  water  it  acts  more 
speedily,  and  a  thin  cloth  should  be  placed  between  it  and  the  skin, 
so  that  it  can  be  readily  removed  when  the  desired  effect  has  been 
produced. 

The  other  rubefacients  mentioned  may  be  applied  either  with  or 
without  friction,  and  should  be  continued  until  the  skin  becomes 
red,  and  then  the  increased  vascularity  may  be  rendered  permanent 
by  the  warm-water  dressing  or  vinegar,  which  is  preferable  to  water, 
because  it  irritates  but  rarely  vesicates  the  part  to  which  it  has  been 
applied. 

Vesicants. — The  most  efficacious  and  convenient  vesicants  are  am- 
monia and  cantharides.  The  former  acts  most  speedily,  and  when 
the  endermic  use  of  morphia  is  necessary,  it  should  be  preferred. 
A  blister  can  be  drawn  in  a  few  minutes  by  applying  four  or  five 
double  of  paper  wet  with  strong  spirits  of  ammonia,  which  should 
be  covered  with  oiled  silk  to  protect  the  thumb,  with  which  it 
should  be  held  firmly  in  contact  with  the  skin  until  vesication  is 
produced.  So  soon  as  the  cuticle  is  detached,  half  a  grain  of  the 
sulphate  of  morphia  should  be  applied,  and  retained  by  the  applica- 
tion of  a  fold  of  wet  printers'  paper.  Cantharides  are  usually 
employed  when  it  is  not  necessary  to  vesicate  the  part  so  speedily. 


LECTURE    IV.  —  COUNTER-IRRITANTS.  55 

Birt's  blistering  fluid  is  superior  to  any  other  preparation.  Strangury 
seldom  results  from  this  application,  an  accident  which  is  usually 
the  most  distressing  consequence  to  be  apprehended  from  an  ordinary 
blister,  and  one  which  when  it  occurs,  is  more  painful  than  the  dis- 
ease for  which  it  has  been  applied.  When  that  preparation  cannot  be 
obtained,  either  the  common  blistering  ointment  or  tissue-paper  may 
be  substituted.  They  should  be  allowed  to  remain  five  or  six  hours, 
and  when  removed  the  water-dressing  should  be  applied,  and  con- 
tinued until  the  discharge  from  the  irritated  surface  subsides.  There 
are  other  local  remedies  which  you  may  find  it  necessary  to  employ. 

Issues  may  be  established  by  making  an  incision  about  an  inch 
in  length,  in  which  two  or  three  issue  peas  should  be  inserted,  and 
retained  by  a  compress  and  bandage.  Formerly  they  were  more 
popular  than  at  present,  although  they  are  unquestionably  much 
more  efficacious  than  some  of  the  counter-irritants  which  have  been 
substituted  for  them. 

I  have  seen  great  relief  afforded  by  them  in  chronic  affections  of 
the  viscera,  both  of  the  thorax  and  abdomen. 

A  more  common  and  fashionable  remedy  in  chronic  inflammation 
is  the  seton,  but  at  the  same  time  it  is  more  painful,  more  trouble- 
some, and  decidedly  more  unpleasant,  because  it  is  impossible,  with- 
out changing  the  cord  frequently,  to  keep  it  sufficiently  clean  to  pre- 
vent it  becoming  offensive. 

A  seton  is  inserted  by  passing  through  an  elevated  portion  of  the 
skin,  a  seton-needle,  either  with  a  skein  of  silk,  a  strip  of  cotton 
cloth,  or  tape,  as  may  be  preferred,  and  it  should  be  allowed  to  remain 
until  the  desired  effect  is  produced. 

After  the  introduction  of  the  seton,  the  warm-water  dressing 
should  be  applied  until  suppuration  is  established,  and  then  simple 
cerate  may  be  substituted.  The  diseases  to  which  this  is  especially 
applicable  will  be  specified  when  under  consideration. 

One  of  the  most  valuable  suppurants  is  ol.  tiglii.  It  has  almost 
supplanted,  if  I  may  use  the  expression,  both  setons  and  issues. 
Should  croton  oil  lose  its  efficacy  by  repetition,  all  that  is  necessary 
is  to  combine  it  with  tart,  antimon.,  5j  of  each  to  half  an  ounce  of 
lard,  to  produce  the  same  effect.  Croton  oil  is  my  favorite  counter- 
irritant,  particularly  when  a  suppurant  is  required.  Before  it  is 
applied,  the  skin  should  be  rubbed  briskly  with  coarse  paper,  until 


56  LECTURES    ON    PRACTICAL    SURGERY. 

considerably  irritated,  and  this  repeated  after  the  application  of  twenty 
or  thirty  drops  of  the  oil.  One  application  usually  produces  suffi- 
cient irritation,  and  should  the  pustulated  surface  become  very  painful, 
it  may  be  dressed  either  with  mutton  suet  or  warm  water,  as  may  be 
most  convenient. 


LECTURE    V.  —  INFLAMMATION. 


UNIVERSITY  OF 


LECTURE    V. 


A  FEW  days  since  I  opened  an  abscess  of  the  liver  which  had  been 
about  four  months  in  forming.  The  patient  was,  at  the  time  of  the 
inception  of  the  disease,  in  a  tropical  climate.  He  there  contracted 
intermittent  fever,  which  apparently  yielded  to  the  ordinary  remedies; 
but  he  did  not  regain  his  health,  and  after  returning  to  this  city  he 
discovered  some  enlargement  of  the  left  side,  which  ultimately  ac- 
quired such  magnitude  as  to  be  exceedingly  inconvenient.  In  order 
to  afford  relief,  an  incision  was  made  with  a  scalpel,  and  two  quarts 
of  pus  escaped.  In  that  case,  chronic  inflammation  resulted  in  sup- 
puration. Ulceration  may  also  occur,  as  in  chronic  gastritis,  accom- 
panied with  dyspeptic  symptoms.  When  this  disease  is  located  in 
the  intestinal  mucous  membrane,  ulceration  frequently  takes  place, 
which  is  true  of  the  cornea  as  well,  in  chronic  ophthalmia.  Adhe- 
sions are  also  very  common  in  chronic  pleuritis,  in  which  the  pleura 
costalis  and  pulmonalis  become  united,  and  the  pleural  cavity  is 
obliterated. 

Induration  also  results  frequently  from  this  form  of  inflammation. 
To  illustrate,  induration  or  enlargement  of  the  lymphatic  ganglia  of 
the  neck  or  groin  may  be  specified.  The  part  inflamed  increases 
gradually  in  size  until  it  attains  a  certain  magnitude ;  it  then  becomes 
solid,  and  is  frequently  stationary,  and  then  you  have  both  induration 
and  enlargement.  You  have  all  seen,  in  the  surgical  ward  of  the 
hospital,  a  man  who  has  a  testicle  which  is  enlarged,  indurated,  and 
suppurating,  which  is  proof  conclusive  that  chronic  inflammation  may 
result  in  induration,  enlargement,  and  suppuration,  and  also  that 
they  may  all  occur  in  the  same  case.  This  is  frequently  observed  in 
scrofulous  subjects.  The  epididymis  becomes  enlarged  and  almost 
as  solid  as  bone.  Your  attention  was  directed  to  two  cases  of  that 
character  in  the  hospital. 

Treatment. — In  chronic  inflammation  the  first  indication  is  to  re- 
move the  cause,  and  then  the  effect,  should  the  latter  still  remain. 
The  diseases  which  result  from  chronic  inflammation  are  so  difficult 
to  treat  that  few  surgeons  acquire  a  reputation  for  their  successful 


58  LECTURES  ON  PRACTICAL  SURGERY. 

management.  The  success  in  such  cases  depends  upon  counter- 
irritation,  and  the  proper  use  of  the  remedies  calculated  to  improve 
the  general  health.  When  chronic  succeeds  acute  inflammation,  the 
opinion  already  expressed  in  reference  to  the  use  of  calomel  is  applica- 
ble to  the  disease  now  under  consideration,  unless  it  be  of  a  scrofulous 
character,  and  in  such  cases  it  is  always  injurious  and  may  be  highly 
dangerous.  Should  the  difficulty  be  of  a  specific  character,  then 
remedies  should  be  administered  which  are  calculated  to  control  that 
peculiar  affection,  and  very  soon,  if  particular  attention  be  paid  to 
diet  and  regimen,  it  will  disappear. 

Should  chronic  inflammation  of  the  lymphatic  ganglia  exist  when 
the  scrofulous  diathesis  is  well  defined,  then  you  should  administer 
the  iodide  of  potassium  in  combination  with  the  fluid  extract  of  stil- 
lingia,  according  to  the  following  formula : 

R.— Pot.  lodid., jjiv. 

Ext.  Still.  Syl.  PI., giij. 

Tinct.  Aconiti  Itad  ,  .         .         .         .         .     gij. 
Syr.  Zingiberis, 

Syr.  Simplicis,  aa gij. 

M.  Sig.  Take  one  teaspoonful  three  times  a  day. 

The  iodide  of  iron  is  exceedingly  useful  in  some  cases  of  this 
character,  and  the  most  convenient  form  of  administration  is  that  of 
Blancard's  pills.  One  should  be  taken  three  times  a  day,  which 
when  combined  with  generous  diet  and  sufficient  exercise  to  secure 
perfect  digestion,  will  generally  relieve  the  difficulty  under  consider- 
ation. In  cases  of  scrofulous  ophthalmia  accompanied  with  exces- 
sive photophobia,  the  general  health  will  improve,  and  the  local 
difficulty  subside  more  rapidly  by  the  use  of  the  following  prescrip- 
tion than  by  any  combination  of  remedies  I  have  ever  administered: 

R. — Quin.  Sulphatis,    ......     ^j. 

Pul.  Rad.  Rhei, 

Sang.  Canadensis, 

Ext.  Cicutae,  aa     ......     £ss. 

M.   Fiant  pil.  No.  xxx.     Sig.  Take  one  pill  four  times  a  day. 

During  the  use  of  these  pills,  the  local  treatment  should  not  be 
neglected  when  the  diseases  of  the  eye  are  under  consideration. 
When  chronic  inflammation  exists  in  any  of  the  abdominal  organs, 


LECTURE    V. GENERAL    TREATMENT.  59 

accompanied  with  indigestion,  constipation,  and  the  debility  insepar- 
able from  insufficient  nutrition,  the  following  mixture  will  be  found 
invaluable.  It  is  laxative,  tonic,  and  sedative,  and  fulfils  the  indi- 
cation in  such  cases  more  perfectly  than  any  other  remedy. 

R.— Ext.  Sennas  Fl giij. 

Tinct.  Nucis  Vomieae,         ....  gix. 
Tinct.  Aconiti  Rad., 

Acid.  Hydrocyanic!,  aa  giss. 
Syr   Zingiberis, 

Syr.  Simplicis,  aa        .....  ^vj. 

M.  Sig.  Take  one  teaspoonful  four  times  a  day  in  water. 

When  prescribed  for  females,  §ss.  more  syrup  should  be  added  to 
the  other  ingredients.  I  have  prescribed  this  mixture  in  thousands 
of  cases,  and  I  have  never  known  any  unpleasant  symptom  to  re- 
sult from  its  use.  The  fluid  extract  of  senna  acts  on  the  liver,  and 
it  is  the  only  laxative  I  have  found  that  does  not  require  to  be  with- 
held occasionally,  in  consequence  of  acting  excessively  on  the  bowels. 
The  tincture  of  nux  vomica  is  the  best  tonic  that  was  ever  admin- 
istered. The  other  ingredients  allay  irritation  and  constitute  a 
valuable  part  of  the  compound.  In  cases  of  anemia,  3iv  of  the 
precipitated  carbonate  of  iron  may  be  added,  and  the  hydrocyanic 
acid  excluded.  You  will  then  have  the  combination  of  a  laxative 
with  the  best  mineral  and  vegetable  tonics,  which  will  disappoint 
as  seldom  as  any  other  that  has  ever  been  administered. 

In  the  treatment  of  such  cases  great  attention  should  be  paid  to 
diet.  Should  the  constitution  of  the  patient  be  good,  and  the  chronic 
affection  the  result  of  an  improperly  treated  case  of  acute  inflamma- 
tion, then  a  mild,  farinaceous,  but  nutritious  diet  should  be  pre- 
scribed, such  as  milk,  sago,  tapioca,  eggs,  custard,  broth,  and  articles 
of  that  character,  in  combination  with  the  constitutional  treatment 
previously  recommended.  When  the  patient  is  naturally  feeble,  or 
the  energy  has  been  impaired  by  disease,  a  generous  diet  should  be 
prescribed.  I  seldom  advise  stimulants  in  such  cases,  but  prefer 
the  remedies  which  are  calculated  to  restore  the  secretions  of  the 
digestive  organs,  and  allow  sufficient  nourishment  to  improve  the 
strength.  Give  as  much  beefsteak,  mutton,  eggs,  and  cream,  as  can 
be  digested,  and  if  the  digestive  organs  be  deranged,  prescribe  the 
remedies  already  specified ;  or  if  acidity  of  the  stomach  exists  give 


60  LECTURES    ON    PRACTICAL    SURGERY. 

the  following  mixture,  which  is  preferable  in  such  cases  to  the  ordi- 
nary alkaline  mixtures  usually  prescribed. 

R.— Acid.  Nitrici, giv. 

Aquae  Destil  ,   .  .         .         .         .     ^ivss. 

M.  Sig.  Take  one  teaspoonful  three  times  a  day  in  a  gill  of  water. 

And  ten  grains  of  the  extract  of  jug.  cathar.  may  be  given  at  night, 
should  the  bowels  be  constipated. 

The  treatment  of  all  the  diseases  which  belong  to  my  department 
will  be  given  hereafter,  and  I  will  now  direct  the  attention  of  the 
class  to  the  terminations  and  results  of  inflammation.  Inflamma- 
tion is  generally  supposed  to  terminate  in  resolution,  ulceration,  or 
gangrene.  It,  however,  only  terminates, 

1st.  By  delitescence. 
2d.  Resolution. 
3d.  Mortification. 

This  application  of  the  word  delitescence  was  made  by  the  French, 
and  is  derived  from  a  Latin  word  which  means  to  abscond.  It  is 
certainly  one  of  the  most  fortunate  terminations  of  inflammation, 
and  the  one  we  should  always  endeavor  to  produce.  Should  a  cold 
be  contracted,  accompanied  with  sore  throat,  chilliness,  and  aching 
of  the  extremities,  with  slight  fever,  all  of  which  are  the  symptoms 
that  usually  precede  acute  inflammation,  in  such  cases  after  bathing 
the  feet  in  warm  water,  and  after  the  patient  is  properly  covered-  in 
bed,  administer  a  pill  composed  of  opium,  ipecac,  and  aloes,  of  each 
one  grain,  and  most  probably  by  morning  the  disease  will  have  ab- 
sconded. If  not  entirely  removed,  however,  a  repetition  of  the 
same  remedies  the  following  evening  will  generally  relieve  the 
difficulty  entirely. 

It  is  always  proper  to  resort  to  this  treatment  even  in  gout  and 
acute  rheumatism,  as  it  affords  temporary  relief  and  will  not  pro- 
duce a  metastasis,  or  in  other  words  change  its  location  to  a  more 
vital  part,  as  would  result  from  the  application  of  a  blister  in  acute 
articular  rheumatism.  I  have  known  rheumatic  inflammation  to  be 
driven  from  point  to  point,  and  ultimately  to  the  heart,  by  blisters, 
which  was  the  treatment  recommended  and  generally  adopted  in 
such  cases  when  I  entered  the  profession. 

Termination  by  Resolution. — When  a  part  that  has  been  inflamed 
assumes  its  natural  appearance,  then  the  inflammation  is  said  to  ter- 


LECTURE    V.  —  MORTIFICATION. 


61 


minate  by  resolution,  and  this  may  even  occur  after  the  deposition 
of  both  serum  and  purulent  matter. 

A  part  may  be  inflamed,  swollen,  and  indurated,  but  if  proper 
means  are  adopted,  the  enlargement  or  congestion  of  the  vessels  will 
diminish  gradually,  and  finally  disappear.  Every  effort  should  be 
made  to  secure  this  termination.  When  an  eye  is  inflamed,  although 
it  may  be  red  and  exceedingly  painful,  yet,  under  proper  treatment, 
the  inflammation  will  gradually  disappear  until  nothing  remains  ex- 
cept a  few  enlarged  vessels,  which  can  speedily  be  removed  by  the 
use  of  a  weak  solution  of  the  nitrate  of  silver  or  the  sulph.  alumina, 
five  grains  to.  the  5j  of  distilled  water. 

Mortification  is  the  third  and  last  termination  of  inflammation. 
This  is  really  a  termination,  because  the  life  of  the  part  implicated 
is  destroyed.  Mortification  may  be  either  acute  or  chronic. 

The  acute  is  accompanied  by  excessive  constitutional  disturbance 
even  if  only  a  limited  portion  of  the  body  be  involved.  The  cuts 
exhibited  represent  the  different  stages  as  the  disease  progresses. 

Fig.  1  represents  an  inflamed  foot  before  mortification  has  occurred. 
Vesicles  have  made  their  appearance,  which  contain  a  dark-colored 


serum.  The  inflammation  extends  above  the  ankle-joint,  and  is 
most  intense  at  the  upper  portion  of  the  discolored  surface,  and  if 
it  presents  that  appearance  the  part  is  gangrenous. 

Fig.  2  represents  the  same  foot  after  it  has  become  more  dark  and 


62 


LECTURES  ON  PRACTICAL  SURGERY. 


is  diminished  in  size,  and  when  it  has  reached  the  second  stage,  and 
the  circulation  has  entirely  ceased,  and  the  line  of  demarcation  is 
very  distinct. 


FIG.  2. 


Fig.  3  represents  the  foot  when  entirely  dead,  the  living  tissues 
having  separated  from  those  deprived  of  vitality.     The  bones  are 


FIG.  3. 


denuded  and  exposed,  and  the  stump  presents  a  healthy  granulating 
surface,  which  is  the  appearance  that  should  exist  before  the  foot  is 
removed. 

The  constitutional  symptoms  of  mortification  are  more  serious  than 
you  would  suppose  could  result  from  the  death  of  so  unimportant  a 
part  of  the  body;  but  a  more  remarkable  peculiarity  is  that  the 


LECTURE    V.  —  MORTIFICATION.  63 

patient  may  be  almost  in  articulo  mortis,  and  yet  if  the  part  be 
removed  in  a  few  hours  the  unfavorable  symptoms  will  entirely 
disappear. 

Causes. — Mortification  may  result  from,  1st.  Excessive  debility,  or 
defective  local  action.  It  is  well  known  that  paralysis,  either  gen- 
eral or  partial,  predisposes  to  that  difficulty,  bed-sores  occurring  in 
such  cases  in  a  few  days,  if  the  proper  precautions  are  not  taken,  in 
consequence  of  defective  local  action;  a  condition  which  also  exists 
in  ossification,  or  a  deposition  of  calcareous  matter  in  the  arteries, 
particularly  of  old  men,  and  which  produces  dry  gangrene,  an  ex- 
ample of  which  is  well  represented  by  Fig.  4  (page  64). 

2d.  Excessive  irritability  or  excessive  irritation.  If  a  blister  be 
applied  to  a  young  child,  although  it  is  not  allowed  to  remain  more 
than  three  or  four  hours,  in  a  few  days  inflammation  may  supervene, 
and  the  entire  surface  become  gangrenous  in  consequence  of  the  ex- 
cessive irritability  of  the  subject.  The  same  application  made  to  a 
healthy  adult,  whether  male  or  female,  will  merely  vesicate,  and  the 
irritation  will  subside  in  a  few  days,  it  being  difficult  in  some  cases 
to  keep  up  a  discharge  from  a  blistered  surface  without  the  assist- 
ance of  some  irritating  application.  I  therefore  repeat  the  advice 
given  in  my  introductory  lecture,  never  to  blister  a  child  except  as  a 
last  resort.  An  illustration  of  the  effect  of  excessive  irritation  is  ex- 
hibited by  the  crushing  of  one  of  the  extremities  by  a  force  which  is 
sufficiently  violent  and  extensive  to  destroy  the  vitality  to  a  con- 
siderable extent.  If  the  injured  part  in  such  cases  be  not  speedily 
removed,  death  will  result  from  the  shock  inseparable  from  such  an 
injury. 

Treatment. — The  first  indication  is  to  control  excessive  action;  cold 
irrigation,  being  the  most  powerful  local  remedy  in  such  cases,  should 
not  be  carelessly  employed.  The  temperature  of  the  part  should 
neither  be  diminished  so  much  as  to  endanger  its  vitality,  nor  kept  in 
that  condition  too  long.  If  you  find,  during  the  treatment  of  acute 
inflammation,  that  the  slightest  evidence  of  gangrene  is  presented, 
warm  applications  should  be  substituted,  and  the  temperature  of 
the  part  elevated. 

The  vitality  of  any  portion  of  the  body  may  be  destroyed  by  the 
constant  application  of  very  cold  water ;  it  is  therefore  necessary, 
when  irrigation  is  employed,  that  the  water  should  not  be  too  cold. 
That  taken  from  a  spring  or  hydrant  is  preferable  to  that  at  a  lower 


64  LECTURES  ON  PRACTICAL  SURGERY. 

temperature.  Should  the  part  present  a  bluish  appearance,  then  it 
should  be  protected  by  an  additional  towel  or  fold  of  soft  porous 
cloth  to  diminish  the  evaporation.  In  the  third  stage  of  mortifica- 
tion there  is  an  entire  separation  of  the  dead  from  the  living  tissues, 
except  the  osseous.  Never  think  of  amputating  until  the  separation 
has  occurred,  and  then  the  operation  is  exceedingly  simple.  The 
soft  parts  should  be  detached  from  the  bone  about  an  inch  above  the 
part  exposed,  and  retained  in  that  position  by  a  retractor,  until  the 
bone  can  be  divided  with  an  amputating  saw.  Many  years  ago  I 
treated  a  young  man,  who  after  being  exposed  to  intense  cold, 
had  his  feet  and  legs  plunged  into  hot,  if  not  boiling,  water,  in  con- 
sequence of  which,  both  legs  mortified  below  the  knees,  and  the 
thighs  were  scalded  so  badly,  that  the  skin  was  entirely  destroyed, 
and  an  extensive  suppurating  surface  resulted.  I  have  never  treated 
so  disagreeable  a  case.  The  bones  were  not  divided  until  they  be- 
came perfectly  denuded,  and  the  patient  recovered  with  the  loss  of 
both  legs,  although  many  months  were  required  to  heal  the  ulcers 
resulting  from  the  application.  Amputation  is  sometimes  performed 
before  the  line  of  demarcation  is  distinctly  defined,  and  then  the  dis- 
ease generally  extends  upwards,  so  as  to  require  a  second  operation, 
which  is  almost  always  fatal. 

Gangrena  senilis,  as  before  stated,  results  from  defective  local 
action  produced  either  by  a  partial  or  an  entire  obliteration  of  the 
arteries  which  supply  the  extremity  with  blood.  The  limb  dimin- 
ishes in  size  gradually,  becomes  black  and  shrivelled,  and  these  symp- 
toms are  accompanied  with  pain  of  the  most  excruciating  character. 

FIG.  4. 


As  there  are  but  few  old  persons  in  California,  I  have  met  with  only 
one  case  during  a  residence  of  fourteen  years.  The  subject  was  a 
native  of  this  State,  and  was  eighty-five  years  of  age.  The  disease 
commenced  in  the  toes  of  the  left  foot,  extended  slowly,  and  when  it 


LECTURE    V. — RESULTS    OF    INFLAMMATION.  65 

had  reached  two  or  three  inches  above  the  ankle,  the  pain,  combined 
with  the  debility  resulting  from  age,  produced  a  fatal  result.  Gan- 
grena  senilis  generally  occurs  in  the  lower  extremities,  but  some- 
times, as  in  Fig.  4,  it  is  located  elsewhere,  and  presents  precisely  the 
appearances  represented  by  that  cut.  In  such  cases,  the  treatment 
can  only  be  palliative.  The  strength  should  be  supported  by  the  use 
of  nutritious  food,  and  the  pain  relieved  either  by  the  administra- 
tion of  opium  or  some  of  its  preparations. 

The  best  local  application  is  cotton  batting.  The  extremity  should 
be  thickly  covered,  and  the  air  excluded  by  the  application  of  a 
bandage.  The  disagreeable  smell  can  be  removed,  either  by  a  solu- 
tion of  the  chlorate  or  permanganate  of  potassa,  the  chloride  of  lime, 
or  any  other  disinfectant.  I  generally  use  the  chlorate  of  potassa, 
Sss.  to  a  quart  of  water,  which  should  be  applied  as  often  as  the  part 
is  dressed,  or  even  more  frequently  if  necessary. 

Having  concluded  what  I  intended  to  say  upon  the  terminations 
of  inflammation,  delitescence,  resolution,  and  mortification,  I  will 
now  consider  the  results  of  inflammation. 

1st.  Effusion,  or  a  Deposition  of  Serum. — This  is  very  common, 
and  occurs  more  frequently  in  the  cellular  and  serous  tissues,  as  the 
eyelids,  and  in  cavities  lined  by  a  serous  membrane,  than  elsewhere. 
It  may  also  result  in  inflammation  of  the  mucous  membrane,  as  in 
oedema  of  the  glottis,  which  may  be  produced  by  exposure  to  cold 
without  being  sufficiently  protected.  You  will  often  find  an  infil- 
tration or  deposition  of  serum  in  the  cellular  tissue  of  the  lower 
extremity  ;  then  it  is  called  anasarca. 

If  pressure  be  made  with  the  finger  upon  any  portion  of  the  dis- 
tended limb,  a  pit  or  depression  will  remain,  which  indicates  the 
character  of  the  effusion.  If  serum  be  deposited  in  the  pleural 
cavity,  it  is  called  hydrothorax ;  in  the  abdomen,  ascites ;  in  the  peri- 
cardium, hydrops  pericardii ;  in  the  cranium,  hydrocephalus ;  and  in 
the  scrotum,  hydrocele.  Every  serous  cavity,  when  inflamed,  is  liable 
to  an  accumulation  of  serum,  which  presents  a  limpid,  yellowish, 
greenish,  or  dark  appearance,  which  depends  on  the  location  and  the 
intensity  of  the  diseased  action.  It  may  also  be  combined  with  both 
blood  and  purulent  matter.  It  is  saline  to  the  taste,  free  from  odor, 
coagulates  readily  by  the  addition  of  either  alcohol,  acids,  or  corro- 
sive sublimate,  and  is  composed  principally  of  albumen,  combined 
with  earthy  sulphates. 

5 


66  LECTURES  ON  PRACTICAL  SURGERY. 

Serum  is  sometimes  deposited  very  rapidly,  of  which  fact  those  of 
you  who  have  been  so  unfortunate  as  to  have  been  stung  by  a  bee, 
wasp,  or  hornet,  are  fully  apprised.  Also  after  a  severe  injury,  the 
part  soon  becomes  enormously  swollen,  which  may  result  from  two 
causes,  the  effusion  of  blood,  and  that  of  serum. 

The  effusion  of  serum  frequently  results  from  the  debility  pro- 
duced by  an  impoverished  condition  of  the  blood.  It  may  depend 
upon  interrupted  venous  circulation,  produced  either  by  enlargement 
of  the  spleen,  liver,  or  other  important  internal  organs.  It  also 
very  frequently  results  from  inflammation  of  the  serous  membranes 
which  line  the  great  and  important  cavities  of  the  body.  Professor 
Gross  thinks  that  serum  may  be  deposited  without  the  existence  of 
inflammation,  but  as  a  general  rule,  serum,  whether  it  occupies  the 
cellular  tissue  or  any  of  the  serous  cavities,  is  one  of  the  results  of 
inflammation. 

Treatment. — Your  remedies  will  depend  entirely  upon  the  cause. 
When  ascites  is  produced  by  an  abnormal  condition  of  the  venous 
circulation,  resulting  from  induration  and  enlargement  of  the  liver, 
or  other  important  abdominal  or  thoracic  organs,  you  must  endeavor 
to  remove  the  cause  by  prescribing  the  treatment  calculated  to  remove 
or  overcome  the  organic  lesion.  In  such  cases  counter-irritants  are 
always  useful,  but  their  extent  and  character  must  be  left  to  the 
judgment  of  the  physician. 

Should  the  effusion  result  from  disease  of  the  liver,  an  effort  should 
be  made  to  restore  secretion  and  remove  the  effusion,  by  the  com- 
bination of  calomel,  squills,  and  digitalis,  according  to  the  following 
recipe  : 

R.—  Submur.  Hyd., 

Pul.  Had.  Scillse,  aa gr.  xvj. 

Pul.  Fol.  Digit., ijr.  viij. 

M.   Fiant  pil.  No.  viii.  Sig.  Take  one  pill  four  times  :\  day. 

These  pills  may  sometimes  be  given  for  three  or  four  days,  without 
ptyalism  being  produced,  and  when  tolerated,  they  form  one  of  the 
most  powerful  diuretics  that  can  be  administered  in  such  cases.  You 
should,  however,  recollect  that  dropsical  patients  are  usually  very 
susceptible  to  the  action  of  mercury,  and  so  soon  as  its  specific  effect 
is  produced,  either  diuretics  or  hydragogues  should  be  substituted, 
and  continued  until  the  serum  is  removed.  There  is  a  combination 


LECTURE    V.  —  DIURETICS    IN    INFLAMMATION.  67 

of  diuretics  which  I  can  recommend,  and  should  that  fail  it  would 
be  useless  to  give  any  other  articles  of  that  class. 

R.— Pot.  Nitratis sjiij. 

Tinct  Fol.  Digit., gj. 

Syr.  Scillse, giij. 

M.  Sig.  Take  one  teaspoonful  every  three  hours,  until  the  desired  effect  is 
produced 

If  the  action  of  the  kidneys  cannot  be  increased,  the  comp.  ext. 
of  elaterium  should  be  given  in  half-grain  doses  every  two  hours, 
until  it  produces  copious  serous  evacuations  from  the  bowels ;  and 
when  that  remedy  fails,  which  frequently  occurs,  then  the  operation 
of  paracentesis  abdominis  should  be  performed.  In  the  mixture 
recommended,  you  will  find  three  of  the  most  powerful  diuretics, 
and  they  rarely  fail  to  remove  serous  effusions,  except  when  they 
result  from  organic  disease  of  the  kidneys,  and  when  these  organs 
have  ceased  to  act,  and  cannot  be  forced  to  perform  their  function. 

Its  effect  was  not  only  striking,  but  extraordinary,  in  a  case  which 
occurred  about  three  years  ago  in  this  city.  M.  Dumas  was  supposed 
by  his  physician  to  be  in  the  last  stage  of  Bright's  disease.  The 
urinary  secretion  was  scanty,  and  composed  of  equal  quantities  of 
urine  and  albumen,  all  the  serous  cavities  were  filled  with  serum,  he 
was  blind,  and  had  a  convulsion  about  every  three  hours ;  he  had 
been  in  that  condition  two  days  before  I  was  called.  Believing  that 
he  might  still  be  saved  if  the  urinary  secretion  could  be  restored,  the 
diuretic  mixture  was  given  every  two  hours,  ice  was  applied  to  the 
head,  and  the  circulation  in  the  extremities  increased  by  the  use  of 
bottles  filled  with  warm  water.  In  twenty-four  hours  the  convul- 
sions ceased,  the  urinary  secretion  was  greatly  augmented,  and  in  less 
than  a  week  he  could  distinguish  surrounding  objects,  the  entire 
serous  effusion  had  disappeared,  and  he  is  now  in  good  health. 

Two  other  cases  of  albuminuria,  which  were  considered  Bright's 
disease,  accompanied  with  many  of  the  symptoms  already  given, 
have  been  recently  relieved  by  the  use  of  that  combination.  These 
cases  should  serve  as  a  caution  to  you  all,  and  prevent  you  from 
placing  yourselves  in  the  same  position.  However  hopeless  a  case 
may  appear,  do  not  despair  of  success,  for  even  in  this  disease  extra- 
ordinary recoveries  take  place.  You  should  therefore  always  give 
the  remedies  indicated,  and  they  may  succeed  even  in  apparently 
desperate  cases. 


68  LECTURES    ON    PRACTICAL    SURGERY. 

In  dropsy  resulting  from  cardiac  disease,  the  diuretic  mixture  should 
be  given  three  or  four  times  in  twenty-four  hours,  and  if  continued 
or  administered  at  short  intervals,  a  patient  by  its  use  may  be  kept 
comfortable  for  months  and  even  years.  Should  the  effusion  result 
from  disease  of  the  liver,  in  consequence  of  a  neglected  intermittent 
fever,  after  it  has  been  removed  by  the  use  of  diuretics,  then  give 
one  pill  four  times  a  day,  prepared  according  to  the  following  for- 
mula : 

&.— Quiniae  Sulph., gj. 

Pul.  Rad.  Rhei, 
"    Sang.  Camidensis, 

Ext.  Cicutse,  aa gss. 

M.  Fiant  pil.  No.  xxx. 

These  pills  prevent  the  recurrence  of  the  fever,  which  is  very  impor- 
tant, and  are  laxative.  Long  experience  enables  me  to  say  that  they 
are  unquestionably  the  most  safe  and  reliable  deobstruent  in  such 
cases  that  can  be  administered.  With  that  combination  alone,  I 
have  cured  many  cases  of  dropsy,  produced  by  enlargement  of  the 
spleen  and  liver,  and  in  malarious  districts  it  is  invaluable,  as  it  is 
the  only  remedy  that  will  prevent  a  recurrence  of  the  paroxysms  of 
intermittent  fever.  When  dropsy  results  from  anaemia,  produced 
either  by  haemorrhage  or  any  other  cause,  then  the  precipitated  car- 
bonate of  iron  is  exceedingly  valuable,  and  may  be  given  either  with 
laxatives  or  alone,  as  may  be  indicated. 

In  ascites,  when  internal  remedies  fail  to  afford  relief,  the  opera- 
tion of  paracentesis  abdominis  should  be  performed.  The  trocar 
may  be  passed  through  the  abdominal  parietes  in  the  linea  alba, 
at  a  point  equidistant  from  the  pubis  and  umbilicus,  and  no  large 
bloodvessels  will  be  endangered.  The  operation  may  also  be  per- 
formed in  the  centre  of  a  line  drawn  from  the  umbilicus  to  the 
superior  anterior  spinous  process  of  the  ilium  with  equal  safety. 
Before  plunging  a.  trocar  into  the  abdominal  cavity,  be  sure  that  it 
contains  serum.  When  the  abdomen  is  distended  by  that  fluid,  if  you 
place  one  hand  on  the  side  and  lower  part  of  the  abdomen,  and  strike 
the  opposite  side  with  the  other  hand,  a  distinct  fluctuation  will  be 
detected.  After  some  experience,  it  is  almost  impossible  to  be  mis- 
taken, yet  a  mistake  may  occur  when  excessive  oedema  exists,  and 
when  a  doubt  is  entertained  it  should  be  removed  by  the  use  of  an 


LECTURE    V.  —  LYMPHIZATION.  69 

ordinary  exploring  needle,  which  may  be  inserted  at  either  of  the 
points  indicated ;  if  the  distension  results  from  an  accumulation  of 
serum,  a  few  drops  will  follow  the  needle  when  removed;  if  the 
distension-  results  from  any  other  cause,  no  serious  inconvenience 
will  result  from  the  operation.  Whenever  a  doubt  exists  always 
use  the  exploring  needle.  It  may  not  be  necessary  after  twenty  or 
thirty  years'  experience,  without  which  no  man  can  diagnose  disease 
with  unerring  accuracy.  I  therefore  repeat,  should  any  doubt  exist 
respecting  the  existence  of  dropsy  of  the  internal  cavities,  always  use 
the  exploring  needle,  and  by  that  it  will  be  removed. 

The  next  result  to  which  I  will  direct  your  attention  is  fibrinous 
exudation,  or  to  use  the  language  of  Prof.  Gross,  lymphization,  a 
term  which  I  think  is  more  expressive,  and  consequently  should  be 
preferred.  It  is  found  wherever  inflammation  exists,  and  particu- 
larly when  the  serous  membrane  is  involved.  In  pleurisy,  adhesions 
take  place  readily  between  the  pleurae  pulmonalis  and  costalis  in  con- 
sequence of  the  tendency  to  lymphization. 

Inflamed  mucous  membranes  also  furnish  lymph,  but  neither  so 
readily  nor  abundantly  as  the  serous  membranes ;  but  when  they 
do,  the  consequences  are  much  more  serious.  The  substance  which 
t  closes  the  larynx  in  membranous  croup  is  nothing  more  than  lymph, 
or  a  fibriuous  exudation  from  the  mucous  membrane.  The  only 
treatment  that  can  be  successful  is  to  dissolve  the  false  membrane  by 
the  administration  of  the  subcarb.  of  potash,  which  may  be  given  to 
children  under  four  years  old  in  doses  of  from  one  to  three  grains 
every  hour  or  two,  according  to  the  urgency  of  the  symptoms.  We 
are  indebted  to  a  German  physician  for  the  discovery  of  this  remedy, 
and  with  it  I  have  saved  children  after  every  other  remedy  had 
failed. 

Except  in  fractures,  the  fibrous  and  osseous  tissues  furnish  but 
little  lymph.  In  six  or  seven  days,  however,  after  such  an  accident 
lymph  is  thrown  out  around  the  extremities  of  the  fractured  bone, 
the  interstices  are  filled,  and  then  ossific  matter  begins  to  be  deposited, 
and  is  continued  until  a  complete  union  of  the  bone  is  accomplished. 

It  is  astonishing  how  soon  the  deposition  of  lymph  commences, 
and  how  rapidly  it  increases.  Prof.  Gross  thinks  that  it  sometimes 
commences  in  an  hour.  In  a  case  in  which  he  operated  for  intus- 
susception, although  the  patient  died  in  four  hours,  he  found  an 


70 


LECTURES    ON    PRACTICAL    SURGERY. 


abundant  secretion  of  lymph  which  had  been  formed  during  that  in- 
terval. A  difference  of  opinion  exists  respecting  its  origin.  Some 
think  that  it  is  a  product  of  the  bloodvessels,  and  is  most  probably  a 
secretion.  Virchow,  however,  believes  that  it  is  an  extra-vascular 
process.  It  is  of  little  consequence  where,  or  how7  it  is  formed,  if  its 
appearance,  properties,  and  use  are  understood. 

In  color  it  is  generally  whitish  or  of  a  pale  straw  color,  but  some- 
times it  presents  a  reddish  appearance.  It  is  composed  of  numerous 
spherical  globules  about  s^^th  of  an  inch  in  diameter,  and  is  iden- 
tical with  the  liquor  sanguinis,  or  blood  liquor,  and  the  buffy  coat. 
It  possesses  vital  properties,  and  when  deposited  in  a  fluid  state,  it 
may  assume  almost  any  form.  The  period  at  which  organization 
commences  is  very  doubtful ;  I  am  satisfied  that  it  begins  very  soon, 
and  sometimes  in  a  few  hours.  For  that  reason,  we  should  always, 
before  closing  a  wound,  when  union  by  the  first  intention  is  desired, 


FIG.  5. 


wait  until  the  surface  becomes  glazed  or  covered  with  lymph,  and 
then,  when  the  edges  are  approximated,  they  unite,  and  the  connect- 
ing medium  becomes  speedily  organized. 

Fig.  5  represents  lymph-globules  recently  formed,  which  have 
been  magnified  three  hundred  and  eighty  diameters.  They  bear  a 
strong  resemblance  to  pus-globules,  and  were  deposited  upon  the 
surface  of  the  pleura. 


LECTURE    V.  —  LYMPHIZATION. 


71 


Fig.   6  represents  a  false  membrane  with  corpuscles  resembling 
primary  cells. 


In  Fig.  7,  you  will  find  nuclei  and  cells  developing  into  fibres. 
Fig.  8  represents  the  fibrous  membrane  after  the  change  has  been 
completed. 


FIG.  7. 


FIG.  8. 


Figs.  9  and  10  exhibit  the  appearance  of  newly  formed  vessels  in 
plastic  lymph. 


72 


LECTURES  ON  PRACTICAL  SURGERY. 


These  illustrations,  I  think,  will  be  sufficient  to  convince  you  that 
recently  effused  lymph  may  assume  almost  any  shape.  It  becomes 
organized  very  readily,  except  in  the  bladder  and  alimentary  canal, 


FIG.  10. 


Vessels  in  false  membranes  of  pleura. 


and  there  such  a  change  never  does  occur,  which  is  exceedingly  for- 
tunate, for  reasons  that  will  be  given  when  the  diseases  of  the  mucous 
membranes  are  under  consideration. 


LECTURE    VI.  —  INFLAMMATION.  73 


LECTURE    VI. 

GENTLEMEN  :  In  this  lecture  the  subject  of  lymphization  will  be 
continued.  After  lymph  has  become  completely  organized,  it  may 
be  absorbed,  an  example  of  which  you  witnessed  at  the  hospital. 

FIG. 11. 


Fibrous  exudation  in  process  of  absorption. 

Another  very  extraordinary  case  occurred  recently  in  my  private 
practice.  The  patient  was  a  resident  of  Sacramento  when  he  con- 
tracted syphilis.  The  chancre  was  located  upon  the  glans  penis,  and 
for  convenience,  the  prepuce  was  drawn  back  so  as  to  expose  the 
ulcer,  and  was  retained  in  that  position  until  a  permanent  paraphi- 
mosis  resulted.  The  glans  penis  was  strangulated  sufficiently  to 
produce  an  enormous  enlargement,  and  the  chancre  had  resisted  the 
treatment  usually  adopted  in  such  cases  for  six  or  eight  months, 
when,  by  the  advice  of  his  physician,  he  visited  San  Francisco  to  have 
the  organ  amputated.  Instead  of  removing  the  glans  penis,  as  he 
desired,  an  ordinary  roller  was  applied  every  day,  until  the  prepuce 
became  detached  by  ulceration ;  it  passed  over  the  glans  as  soon  as 
it  was  reduced  to  its  natural  dimensions,  and  when  the  congestion 
which  resulted  from  the  constriction  disappeared,  the  ulcer  healed. 

Lymph  may  also  be  converted  into  pus.  Whenever  a  part  be- 
comes so  much  inflamed  as  almost  entirely  to  arrest  the  circulation, 
the  lymph  previously  deposited  is  converted  into  pus.  It  is  the 


74  LECTURES    ON    PRACTICAL    SURGERY. 

material  from  which  pus  is  produced,  and  an  abscess  is  formed  by 
the  absorption  of  the  surrounding  parts  for  its  accommodation.  It 
also  furnishes  the  basis  of  analogous  tissue.  It  is  called  analogous, 
because  the  lymph  deposited  in  the  tissue  of  the  part,  when  organ- 
ized, resembles  the  original  structure. 

It  is  also  the  basis  of  heterologous  tissue,  which  is  entirely  different 
from  that  which  composes  the  organ  or  tissue  in  which  it  is  located. 
Heterologous  tissue  may  be  either  tuberculous  or  cancerous,  both  of 
which  differ  in  every  respect  from  all  the  natural  and  healthy  tissues 
of  the  body. 

What  is  the  use  of  lymph  ?  There  are  two  varieties,  which  are 
called  plastic  and  non-plastic.  By  the  former  all  injuries  are  repaired, 
and  without  it  a  wound  would  neither  heal,  nor  a  divided  artery  be 
obliterated.  In  six,  eight,  or  ten  hours,  according  to  the  age  and  the 
constitutional  energy  of  the  patient,  a  sufficient  quantity  of  plastic 
lymph  is  eifused  upon  the  edges  of  the  wound,  for  adhesion  to  take 
place,  provided  they  be  approximated  and  retained  in  contact.  The 
bloodvessels  pass  at  first  into  and  finally  through  the  lymph  effused, 
and  ultimately  the  connecting  medium  becomes  perfectly  organized. 
Some  difference  of  opinion  exists  respecting  the  time  required,  which 
will  be  hereafter  considered. 

It  is  by  the  agency  of  plastic  lymph  that  the  radical  cure  of  hernia 
is  eifected,  which  is  a  very  common  occurrence  in  children  from  the 
application  of  an  ordinary  truss.  The  protruding  part  being  re- 
turned, and  retained  by  a  truss,  sufficient  inflammation  is  produced 
by  the  pressure  it  exerts,  to  secure  such  a  deposition  of  lymph  as 
to  unite  the  opposed  surfaces  of  the  inguinal  canal,  and  when  per- 
fectly organized,  the  union  is  sufficiently  firm  to  prevent  a  recurrence 
of  the  difficulty.  It  sometimes  isolates  foreign  bodies.  In  a  gun- 
shot wound,  when  a  ball  has  not  sufficient  velocity  to  pass  through 
the  part  it  enters,  and  it  occupies  an  inaccessible  position,  a  sufficient 
quantity  of  plastic  lymph  is  often  deposited  to  form  a  cyst,  by  which 
it  is  isolated  and  rendered  no  longer  offensive  to  the  surrounding 
parts. 

In  internal  abscesses,  either  of  the  lungs  or  liver,  the  sac  is  formed 
in  the  same  manner,  and  when  the  pus  approaches  the  surface  of  the 
organs,  adhesions  of  the  serous  membranes  take  place  by  its  agency, 
and  the  effusion  of  pus,  either  into  the  pleural  or  peritoneal  cavities, 
is  prevented. 


LECTURE    VI.  —  FORMATION    OF    LYMPH.  75 

It  also  obliterates  serous  cavities,  which  is  illustrated  in  hydrocele. 
If  the  scrotum  be  punctured  with  a  trocar,  the  fluid  removed,  and 
the  comp.  tincture  of  iodine  diluted  with  an  equal  quantity  of  water 
be  injected,  and  allowed  to  remain  five  minutes,  the  cavity  which 
contained  the  serum  will  either  be  obliterated,  or  cease  to  secrete  that 
fluid,  which  formerly  produced  the  distension. 

Although  it  is  invaluable  in  the  cases  enumerated,  and  without  its 
agency  it  would  be  impossible  for  the  surgeon  to  accomplish  any- 
thing by  which  a  reputation  could  be  obtained,  yet  serious  conse- 
quences may  result  from  its  presence  under  certain  circumstances. 
The  natural  outlets  of  the  body  may  be  obstructed,  as  in  membra- 
nous croup  and  diphtheria.  In  the  former  the  lymph  is  generally 
deposited  in  the  larynx,  becomes  organized,  and  as  soon  as  the  open- 
ing is  sufficiently  contracted  to  prevent  the  oxygenation  of  the  blood, 
the  patient  will  die  of  asphyxia.  In  diphtheria,  besides  the  mucous 
membranes  of  the  nares  and  larynx,  that  of  the  trachea  becomes 
speedily  and  so  extensively  implicated,  that  it  is  really  incurable. 
Should  tracheotomy  be  performed  to  admit  the  air,  the  cavity  will  be 
found  so  contracted  that  in  a  majority  of  cases  no  benefit  will  result. 
I  have  performed  the  operation  of  tracheotomy  four  times  in  diph- 
theria, and  have  resolved  in  such  cases  never  to  repeat  it.  Abnor- 
mal adhesions  also  exist,  as  in  the  thorax,  but  they  usually  produce 
little  inconvenience.  When  the  articulating  surfaces  are  allowed  to 
remain  too  long  in  the  same  position,  or  become  inflamed,  plastic 
lymph  may  be  effused,  and  when  organized  the  joint  is  permanently 
anchylosed.  Such  a  result  is  exceedingly  common  after  fractures  of 
the  thigh,  particularly  if  they  be  compound  and  do  not  unite  readily, 
by  which  the  patient  is  required  to  remain  in  the  same  position  for 
several  months.  Anchylosis  should  never  occur  in  such  cases,  and 
when  it  does,  it  results  either  from  the  ignorance  or  negligence  of 
the  surgeon.  It(is  exceedingly  important  in  the  treatment  of  frac- 
tures of  the  extremities  to  flex  and  extend  them  at  least  every  week. 
If  the  patient  be  forty  years  of  age,  and  has  been  accustomed  to  hard 
labor,  if  that  precaution  be  neglected,  the  joints  become  stiff  in  three 
or  four  weeks,  and  in  two  months  they  will,  unless  great  force  is  em- 
ployed, be  immovable.  Induration  and  enlargement  both  result 
from  inflammation,  and  are  produced  by  the  deposition  and  organi- 
zation of  plastic  lymph.  They  should  be  treated  by  antiphlogistics 
and  sorbefacients  of  a  more  or  less  active  character,  according  to  the 


76  LECTURES    ON    PRACTICAL    SURGERY. 

peculiarities  of  the  case.  As  a  local  application  the  tincture  of  iodine 
is  generally  better  than  any  other  remedy  of  that  class,  although 
great  benefit  frequently  results  from  the  use  of  mercurial  ointment, 
and  in  some  cases  it  will  be  found  superior  to  any  other  remedy. 
In  enlargement  and  induration  of  the  testicle,  it  should  be  preferred, 
as  the  tincture  of  iodine  cannot  be  applied  to  the  scrotum  without 
producing  pain  sufficient  to  counteract  the  ordinary  effect  of  the 
remedy. 

Enlargements  of  the  spleen  and  tonsils  result  from  the  same  cause. 
The  spleen  becomes  enlarged  in  malarious  districts  of  country,  and 
may  remain  in  that  condition  during  a  long  life,  provided  the  patient 
be  exposed  to  the  cause  by  which  it  was  originally  produced.  Re- 
move him  from  that  locality,  and  give  him  one  pill  four  times  a  day, 
composed  of  qui.  sulph.,  rheum,  sang,  canad.,  and  cicuta,  in  the  pro- 
portions previously  recommended,  and  the  enlargement  and  indu- 
ration will  soon  entirely  disappear.  When  the  tonsils  become  en- 
larged they  should  be  removed,  and  suitable  remedies  prescribed  to 
counteract  the  tendency  that  exists  in  such  cases  to  disease,  both  of 
the  mucous  membrane  and  lymphatic  ganglia. 

Suppuration. — The  next  result  which  presents  is  suppuration.  By 
this  we  understand  the  formation  of  a  peculiar  fluid  called  pus.  It 
is  opaque,  about  the  consistence  of  cream,  presents  a  pale  yellow  or 
straw  color,  and  when  microscopically  examined,  globules  appear 
floating  in  a  transparent  fluid.  Pus  always  sinks  in  water,  which 
should  be  remembered,  as  it  may  enable  you  to  make  a  more  correct 
diagnosis  in  some  cases  of  pulmonary  disease.  It  should  not  be  for- 
gotten, however,  that  when  it  is  combined  with  mucus  it  presents 
the  appearance  of  that  fluid,  and  floats  as  readily  when  placed  in 
water. 

It  coagulates  or  becomes  consistent  by  the  application  both  of 
heat  and  muriate  of  ammonia. 

The  formation  of  pus  generally  indicates  the  existence  of  a  higher 
degree  of  inflammatory  action  than  is  required  either  for  the  effusion 
of  serum  or  lymph,  although  some  think  that  pus  may  be  found 
without  the  existence  of  inflammation. 

It  is  true  that  when  the  general  health  is  greatly  impaired,  the 
formation  of  pus'is  accompanied  with  but  few  of  the  evidences  of  in- 
flammation, yet  it  is  difficult  to  believe,  even  in  cases  of  cold  abscess, 
that  imperfect  pus  can  be  formed  without  increased  local  vascular 


LECTURE    VI.  —  SUPPURATION.  77 

action,  which  always  varies  in  different  cases  and  constitutions.  Pus 
is  unquestionably  a  secretion.  It  is  prepared  by  the  capillary  vessels, 
and  it  may  take  place  either  with  or  without  a  solution  of  continuity. 
The  serous  membranes,  as  the  pleura  and  peritoneum,  furnish  it 
most  abundantly,  yet  when  the  mucous  membranes  are  inflamed  pus 
is  frequently  secreted.  It  varies  in  color  as  well  as  in  consistence 
and  other  properties,  either  from  an  admixture  with  blood,  bloody 
serum,  or  mucus,  or  from  the  peculiarity  of  the  part  affected,  and 
the  condition  of  the  patient.  The  formation  of  pus  may  be  either 
superficial  or  interstitial.  It  is  said  to  be  superficial  when  formed 
by  the  mucous  membrane  of  the  urethra,  by  the  conjunctiva,  or  the 
mucous  membrane  lining  the  bronchial  tubes.  It  is  interstitial 
when  the  secretion  takes  place  under  the  skin,  or  in  the  texture  of 
an  organ  ;  and  it  is  then  called  an  abscess,  which  is  said  to  be  cir- 
cumscribed when  its  extent  is  limited  by  the  effusion  of  lymph, 
phlegmonous  when  it  results  from  excessive  vascular  action,  and 
cold  when  but  little,  if  any,  perceptible  increase  of  heat  is  observed. 
In  erysipelas,  there  is  usually  an  absence  of  pus.  When  it  assumes 
a  phlegmonous  character,  pus  frequently  forms  in  the  subcutaneous 
cellular  tissue,  and  even  under  the  pericranium,  producing  an  exten- 
sive exfoliation  of  bone. 

As  soon  as  pus  is  secreted,  or  in  other  words,  as  soon  as  suppura- 
tion takes  place,  both  the  pain  and  tension  diminish,  and  fluctuation 
becomes  distinct. 

When  suppuration  takes  place  internally,  besides  the  diminution 
of  pain,  rigors  occur  at  irregular  intervals,  and  they  do  not  yield  to 
the  treatment  necessary  in  intermittent  fever.  The  contents  of  an 
abscess  may  be  removed,  or  in  other  words,  pus  may  be  absorbed 
without  producing  any  constitutional  disturbance.  Modern  pathol- 
ogists  believe  that  pus-globules  are  not  absorbed  entire.  They  be- 
come disintegrated,  the  fluid  portion  is  absorbed,  and  the  remainder 
produces  no  local  inconvenience. 

In  some  cases,  a  small  abscess,  even  of  a  syphilitic  character,  may 
disappear  without  increasing  the  danger  of  secondary  disease. 

Whenever  an  abscess  acquires  considerable  magnitude,  absorption 
rarely  occurs.  The  contents  usually  find  their  way  either  to  the 
surface  of  the  body,  the  bronchial  tubes,  intestinal  canal,  or  to  some 
other  natural  outlet,  and  very  rarely  break  into  an  open  cavity. 
An  abscess  should  always  be  opened  as  soon  as  fluctuation  is  distinct : 


78  LECTURES  ON  PRACTICAL  SURGERY. 

by  pursuing  this  course,  pain  is  relieved,  there  is  less  destruction 
of  the  surrounding  cellular  tissue,  the  cicatrix  is  smaller,  and  the 
danger  of  extensive  ulceration  occurring  in  the  attenuated  parietes, 
which  results  from  delay,  is  entirely  removed. 

When  I  am  not  permitted  to  open  an  abscess  at  the  proper  time, 
particularly  if  it  be  located  upon  an  exposed  portion  of  the  body,  I 
advise  the  application  of  poultices  until  the  integument  is  removed 
by  the  absorbents,  because  when  opened  too  late,  if  the  patient  be 
disfigured  by  the  cicatrix,  the  physician,  whether  he  has  erred  or  not, 
is  always  censured. 

An  abscess  may  be  opened  with  a  lancet,  a  small  bistoury,  or  by 
the  application  of  caustic  potash.  I  generally  use  a  thumb  lancet, 
because  it  is  more  convenient,  is  less  dreaded,  and  makes  an  opening 
sufficiently  free  to  allow  the  contents  to  escape  readily.  An  ordinary 
tenotomy  knife  is  an  admirable  instrument  for  opening  small  ab- 
scesses upon  the  neck  and  face,  and  with  it  you  can  make  either  a 
large  or  small  incision  as  may  be  necessary.  Caustic  potash  may  be 
employed,  when  an  extraordinary  dread  of  cutting  instruments  exists. 
After  the  covering  has  become  attenuated,  one  grain  should  be 
applied  upon  the  most  prominent  part,  and  retained  by  the  use  of  a 
strip  of  adhesive  plaster.  In  two  or  three  hours  the  vitality  of  the 
part  will  be  destroyed,  and  an  opening  can  be  made  either  with  a 
lancet  or  bistoury  without  giving  the  slightest  pain.  Should  the 
patient  prefer,  apply  the  warm-water  dressing  or  a  poultice  until  the 
slough  separates  and  allows  the  pus  to  escape.  After  opening  an 
abscess,  a  small  portion  of  wet  lint  should  be  inserted.  The  quantity 
should  not  be  sufficient  to  produce  painful  distension,  but  only 
enough  to  prevent  union  by  the  first  intention,  and  then  either  the 
warm-water  dressing  or  a  poultice  may  be  applied,  according  to  the 
location  of  the  part  or  prejudice  of  the  patient.  The  dressing  should 
be  changed  as  often  as  necessary  to  preserve  cleanliness.  Should  the 
abscess  be  large,  and  the  discharge  abundant,  it  should  be  dressed 
two  or  three  times  in  twenty-four  hours,  and  even  more  frequently 
in  very  warm  weather,  particularly  if  it  be  offensive.  An  abscess  is 
said  to  be  cold  when  it  is  neither  preceded  by  pain,  nor  the  other 
evidences  of  the  existence  of  acute  inflammation. 

The  diseases  liable  to  be  mistaken  for  an  abscess  are  encephaloid, 
aneurism,  and  hernia.  The  inexperienced  may  find  some  difficulty  in 
distinguishing  a  tumor  of  an  encephaloid  character  from  an  abscess, 


LECTURE    VI.  —  DIAGNOSIS    OF    ABSCESS.  79' 

the  elasticity  of  the  tumor  being  mistaken  for  fluctuation,  when  the 
size,  location,  and  the  time  required  for  the  development  of  this 
variety  of  malignant  tumor  be  taken  into  consideration.  I  think 
such  mistakes  should  not  occur  very  frequently.  In  two  cases  in 
this  city,  in  one  of  which  the  tumor  was  located  on  the  posterior 
and  lateral  portion  of  the  pelvis,  and  the  other  on  the  superior  and 
left  side  of  the  thorax,  encephaloid  has  been  mistaken  for  abscess 
and  opened.  Each  weighed  about  seven  pounds,  and  had  acquired 
that  magnitude  in  a  few  weeks.  They  were  not  painful  until  they 
became  so  by  their  size,  and  yet  the  error  of  diagnosis  was  made  by 
physicians  of  more  than  twenty  years'  experience.  I  mention  these 
cases  to  render  you  more  cautious,  and  before  you  express  an  opinion, 
if  a  doubt  is  entertained,  always  use  the  exploring  needle.  It  gives 
but  little  pain,  and  is  never  followed  either  by  haemorrhage  or  any 
other  serious  inconvenience,  without  regard  to  where  it  has  been  in- 
troduced. 

You  should  always  be  able  to  distinguish  an  abscess  from  an 
aneurism,  by  the  strong  pulsation  that  exists  in  the  latter,  as  well  as 
by  the  absence  both  of  pain  and  discoloration  of  the  skin  ;  and  still 
mistakes  of  that  character  are  made.  About  four  months  ago  I  was 
requested  to  see  a  gentleman  of  this  city,  who  had  experienced 
considerable  inconvenience  from  a  tumor  in  the  left  axilla.  It  was 
covered  by  a  flaxseed  poultice,  and  I  was  told  that  his  physician,  who 
was  one  of  the  most  experienced  practitioners  in  the  city,  considered 
it  an  abscess,  and  intended  to  open  it  in  the  morning,  and  conse- 
quently they  were  anxious  to  have  my  opinion  before  the  operation 
was  performed.  I  found  a  firm,  pulsating  tumor,  without  either 
elasticity  or  fluctuation.  I  directed  his  friends  to  send  for  the  phy- 
sician, and  tell  him  that  I  thought  it  was  an  aneurism,  and  probably 
he  might  pursue  a  different  course  of  treatment. 

AVhen  tumors  appear  upon  the  upper  part  of  the  thigh,  in  the 
groin,  or  on  the  inferior  portion  of  the  abdomen,  the  history  of  the 
case  should,  if  possible,  be  obtained  when  any  obscurity  exists.  An 
inguinal  abscess  usually  commences  as  a  small,  hard,  and  painful 
tumor  in  the  groin,  while  inguinal  hernia  makes  its  appearance  above 
Poupart's  ligament,  about  three  inches  from  the  anterior  superior 
spinous  process  of  the  ilium,  and  is  not  accompanied  with  pain.  In 
ordinary  cases  the  enlargement  disappears  when  the  recumbent  posi- 
tion is  assumed,  but  when  any  portion  of  the  abdominal  contents 


80  LECTURES    ON    PRACTICAL    SURGERY. 

escapes,  in  consequence  of  a  violent  muscular  effort,  very  soon  the 
symptoms  of  strangulated  hernia  will  appear.  Such  a  difficulty 
should  not  be  mistaken  for  an  abscess,  neither  should  incarcerated 
hernia,  which  must  have  existed  longer  than  is  required  for  the 
formation  of  an  abscess.  Whenever  you  find  it  difficult  to  decide, 
always  bring  the  exploring  needle  to  your  relief. 

Prognosis. — The  prognosis  will  depend  upon  the  character  and  loca- 
tion of  the  swelling,  as  well  as  upon  the  constitution  of  the  patient. 
A  simple  abscess,  produced  by  a  contusion,  or  which  results  from 
acute  inflammation,  is  neither  important  nor  dangerous.  Should  an 
abscess  be  located  in  the  lumbar  region,  or  present  in  the  groin, 
below  Poupart's  ligament,  without  being  preceded  by  the  symptoms 
which  usually  accompany  inflammation,  then  you  should  suspect 
the  existence  of  caries  of  some  portion  of  the  vertebral  column, 
which  sooner  or  later  must  prove  fatal.  In  such  cases,  your  prog- 
nosis should  conform  with  the  condition  of  the  patient.  As  soon  as 
an  abscess  of  that  character  is  opened,  whether  by  an  incision  or  by 
the  absorption  produced  by  pressure,  hectic  fever  follows,  and  in  a 
few  months  the  patient  is  exhausted  by  the  purulent  discharge,  ex- 
cessive perspiration,  and  colliquative  diarrhoaa  which  always  exist  in 
a  difficulty  of  that  character. 

Treatment. — Always  .endeavor  to  treat  inflammation  in  such  a 
manner  as  to  cause  it  to  terminate  by  resolution.  Should  you  find, 
however,  that  such  a  result  cannot  be  obtained,  then  apply  either 
the  warm-water  dressing  or  a  poultice  constantly,  until  fluctuation 
becomes  distinct,  when  an  opening  should  be  made  and  the  case 
treated  as  before  directed. 

There  is  another  difficulty  of  this  character,  which  is  much  more 
serious  than  an  ordinary  abscess,  and  is  called  diffuse  or  multiple 
abscess,  pyaemia,  or  purulent  infiltration,  terms  which  are  applied  to 
the  same  disease.  This  kind  of  abscess  may  result  from  any  wound 
or  injury,  and  should  be  particularly  dreaded  in  phlegmonous  ery- 
sipelas. When  phlebitis  results  either  from  operations  upon  or  inju- 
ries of  the  veins,  which  will  hereafter  be  considered,  the  symptoms 
usually  attributed  to,  and  supposed  to  result  from  purulent  infil- 
tration, are  always  present ;  consequently  I  believe  that  phlebitis  is 
the  most  fruitful  source  of  this  dreadful  disease. 

Sometimes,  in  a  few  days  after  a  simple  operation,  the  patient  after 
complaining  of  being  chilly,  will  experience  pain  either  in  the  wrist 


LECTURE    VI.  —  MULTIPLE    ABSCESSES.  81 

or  in  some  other  joint.  The  chill  will  be  followed  both  by  a  hot  and 
a  sweating  stage,  which,  by  the  inexperienced,  might  be  mistaken  for 
an  attack  of  intermittent  fever,  if  it  were  not  accompanied  by  the 
pain  in  one  or  more  of  the  articulations,  and  if  the  paroxysms  did  not 
return  more  frequently  than  in  ordinary  cases  of  a  malarious  char- 
acter. Sometimes,  in  a  few  days  after  these  symptoms  appear,  the 
breathing  becomes  difficult  in  consequence  of  the  infiltration  of  pur- 
ulent matter  in  the  substance  of  the  lungs,  and  the  patient  will  die 
after  suffering  for  a  few  days  with  all  the  symptoms  of  typhoid 
pneumonia. 

In  puerperal  cases,  frequently  at  the  fourth  or  fifth  day,  and  some- 
times without  there  being  previously  any  decided  symptoms  of  peri- 
tonitis, the  patient  will  complain  of  pain  in  one  or  more  of  the  joints 
accompanied  with  fever,  and  the  other  phenomena  which  characterize 
this  disease.  These  symptoms  should  always  be  regarded  as  of  a  very 
serious  character,  because  they  result  either  from  phlebitis  or  puru- 
lent absorption  from  the  suppurating  surface,  produced  by  the  de- 
tach ment  of  the  placenta. 

Usually  in  such  cases  the  symptoms  become  more  and  more  aggra- 
vated, although  the  patient  may  live  from  one  to  three  weeks,  accord- 
ing to  the  parts  implicated  and  the  extent  of  the  deposit.  When 
either  the  liver,  lungs,  or  other  internal  vital  organs  are  implicated, 
the  disease,  which  is  almost  always  fatal,  will  terminate  much  more 
speedily  than  if  it  had  been  confined  exclusively  to  the  joints.  I 
said  that  this  disease  is  almost  always  fatal,  which  is  unfortunately 
too  true;  the  following  constitutes  a  rare  exception. 

Mrs.  C.,  aged  about  50  years,  being  annoyed  by  a  fibrous  tumor 
on  the  neck,  it  was  removed,  and  I  endeavored  to  heal  the  wound 
by  the  first  intention.  On  the  fourth  night  after  the  operation  she  had 
a  chill,  which  was  followed  by  fever  and  a  pain  in  the  left  wrist- 
joint.  The  wound  was  opened  and  lint  wet  with  tinct.  opii,  aqua 
ammonise,  with  double  the  quantity  of  aqua  destil.,  was  inserted,  and 
the  water-dressing  applied.  A  depressant  mixture  was  administered 
to  control  the  fever,  and  in  three  or  four  days,  the  unfavorable 
symptoms  had  all  disappeared.  I  am  satisfied  that  her  recovery  re- 
sulted from  the  change  of  treatment,  and  since  then  I  have  not  at- 
tempted to  heal  such  a  wound  by  the  first  intention.  You  should 
always  leave  the  most  dependent  part  of  the  wound  open,  for  the 
purpose  of  allowing  the  secretions,  both  serous  and  purulent,  to 

6 


82 


LECTURES    ON    PRACTICAL    SURGERY. 


escape  readily,  in  order  to  prevent  the  occurrence  of  pyaemia,  which 
is  the  most  dangerous  complication  that  could  arise  during  the  treat- 
ment of  a  severe  injury,  whether  it  results  from  an  operation  or  is 
produced  by  accident. 

A  scrofulous  abscess  differs  from  the  ordinary  variety,  both  in  its 


FIG.  12. 


FIG.  13. 


Puriform  fluid  from  a  softened  lymphatic  gland. 


Pus-globules. 


progress  and  the  appearance  of  the  pus  secreted,  as  may  be  seen  by 
referring  to  Fig.  12.     Under  this  head  hectic  fever  should  be  consid- 


FIG.  14. 


Pus  from  a  scrofulous  abscess. 


ered,  but  before  taking  up  that  subject  I  beg  leave  to  direct  your 
attention  to  the  appearance  under  the  microscope  of  healthy  pus- 
globules,  as  well  as  the  varieties  which  we  should  expect  to  find  in 
scrofula  and  the  other  morbid  conditions  of  the  system. 


LECTURE    VII.  —  RESULTS    OF    INFLAMMATION.  83 


LECTURE   VII. 

GENTLEMEN  :  This  morning  I  propose  to  say  a  few  words  re- 
specting haemorrhage  as  a  result  of  inflammation,  which  is  so  rare 
that  I  have  only  met  with  one  case  in  either  this  or  my  native  State. 
The  case  referred  to  occurred  only  a  few  weeks  since,  and  followed 
an  operation  for  varicocele  performed  in  a  young  man  of  sanguine 
temperament,  and  of  an  exceedingly  full  habit.  Until  the  second 
day  after  the  operation  the  parts  were  neither  unusually  inflamed,  nor 
very  painful,  but  then  the  scrotum  became  red  and  enormously  dis- 
tended by  an  extravasation  that  had  occurred  between  the  tunica 
vaginalis  and  testicle.  When  an  incision  was  made  at  least  half  a 
pint  of  blood  escaped.  The  vein  was  not  wounded,  and  nothing 
unusual  occurred  until  the  third  day,  when  the  parts  became  in- 
flamed. So  soon  as  the  distension  was  removed,  the  inflammation 
subsided  rapidly  under  the  application  of  cold  water.  In  four  or 
five  days  both  the  pain  and  swelling  had  disappeared,  and  the  re- 
sult of  the  operation  was  as  satisfactory  as  if  the  haemorrhage  had 
not  occurred. 

Absorption. — We  understand  by  absorption  the  removal  of  tissues 
more  rapidly  than  they  are  furnished  by  the  nutrient  vessels.  In 
other  words,  whenever  absorption  is  more  active  than  nutrition,  ul- 
ceration  must  result,  and  may  be  either  superficial  or  interstitial. 

When  it  commences  in  the  skin  it  is  said  to  be  superficial.  A  small 
portion  of  the  cuticle  may  be  detached  by  violence,  or  a  vesicle  may 
appear,  which  if  neglected  or  irritated  may  extend,  and  in  a  short 
time  become  an  ulcer  of  considerable  magnitude.  Pressure  is  the 
most  common  cause  of  absorption,  whether  it  be  superficial  or  inter- 
stitial, consequently  when  pressure  is  made  by  the  distended  vessels 
of  a  part  inflamed,  the  ulceration  continues  to  extend  until  the  in- 
ordinate vascular  action  is  controlled. 

Nutrition  ceases  so  soon  as  inflammation  occurs,  and  absorption 
becomes  more  active  in  consequence  of  the  pressure  produced  by  the 
distended  vessels.  Ulceration  may  also  result  from  the  effusion  or 
secretion  of  pus,  or  from  the  presence  of  other  substances  which  do 


84  LECTURES    ON    PRACTICAL    SURGERY. 

not  naturally  belong  to  the  part  affected.  When  pus  is  secreted 
under  the  skin,  whether  it  be  superficial  or  deepseated,  the  pressure 
it  exerts  increases  the  action  of  the  absorbents,  by  which  the  parts 
that  intervene  between  the  fluid  and  the  integument  are  more  or  less 
rapidly  removed,  and  when  the  skin  yields  to  the  pressure,  and  the 
contents  escape,  an  ulcer  is  produced. 

Fluids  and  even  pus  may  be  removed  without  the  occurrence  of 
ulceration,  when  the  pressure  is  not  great,  and  the  cause  not  very 
active,  by  the  application  externally  of  counter-irritants  and  sorbe- 
facients.  The  best  sorbefacient  is  the  tincture  of  iodine,  but  if  the 
part  be  irritable,  it  may  be  combined  with  an  equal  quantity  of  the 
tincture  of  arnica.  The  best  vesicant  I  know  of  is  that  sold  under 
the  name  of  "  Birt's  blistering  fluid  ;"  it  vesicates  in  a  few  hours ;  it 
is  very  certain  in  its  effect,  and  it  rarely  causes  strangury,  which  is  one 
of  the  most  distressing  consequences  attending  the  application  of  an 
ordinary  blistering  plaster. 

When  pus  is  secreted  interstitially,  ulceration  of  the  skin  does  not 
necessarily  result.  What  is  an  ulcer  ?  The  most  concise  definition 
which  I  can  give  is  that  it  is  a  solution  of  continuity  which  secretes 
pus.  When  a  wound  does  not  heal  within  twenty -four  hours,  union 
by  the  first  intention  becomes  impossible,  and  then  you  have  what  is 
called  an  ulcer.  For  several  hours  after  a  wound  is  received  there 
is  a  discharge  of  serum  mixed  with  more  or  less  blood,  according  to 
the  location  of  the  injury;  when  that  ceases,  lymph  is  deposited,  and 
by  the  third  day  it  is  usually  sufficiently  organized  for  red  points  to 
make  their  appearance,  which  are  called  granulations.  They  are 
when  healthy  both  red  and  rounded,  and  they  are  small  in  propor- 
tion to  the  health  and  constitutional  vigor  of  the  patient.  They 
bleed  when  touched,  and  sometimes  are  exceedingly  sensitive.  I  do 
not  think  that  I  can  describe  granulations  so  that  you  will  under- 
stand their  appearance,  variety,  and  peculiarities  so  well  as  by  the 
study  of  a  specimen.  Fig.  15  represents  an  inflamed  and  spreading 
ulcer.  Absorption  is  more  active  than  nutrition,  and  the  time  that 
elapses  from  its  origin  until  it  is  arrested  is  called  the  period  of  ex- 
tension. After  it  has  ceased  to  extend,  and  before  it  begins  to  heal, 
the  period  of  arrest  and  the  process  by  which  an  ulcer  is  healed,  is 
called  cicatrization. 

So  long  as  an  ulcer  is  violently  inflamed  it  always  enlarges.  Con- 
trol the  inflammation  by  suitable  remedies,  and  plastic  lymph  is 


LECTURE    VII.  —  ULCERATION. 


85 


effused  around  the  edges,  and  forms  a  ring  which  encircles  the  ulcer 
and  arrests  its  progress.  The  surface  is  also  covered  with  lymph, 
which  becomes  vascular,  and  granulations  soon  make  their  appear- 
ance. A  single  granule  is  transparent,  but  two  or  more  present  a 


FIG.  15. 


Inflamed  irritable  ulcer. 

red  appearance,  which  becomes  more  intense  with  increased  vascu- 
larity.  It  is  an  interesting  question  how  the  blood  finds  its  way  into 
these  granulations.  The  vessels  form  in  loops,  and  from  them 
branches  spring  out  and  extend  until  the  circulation  is  established, 
and  it  is  astonishing  with  what  rapidity  the  necessary  supply  of  blood 
is  furnished.  In  my  clinical  lectures  I  have  said  repeatedly  that  an 
ulcer  will  not  heal  so  long  as  the  surface  is  below  the  edges.  In  in- 
dolent callous  ulcers  which  do  not  heal  from  defect  of  action,  there  is 
no  remedy  by  which  their  character  can  be  changed  except  pressure. 
Apply  a  roller  bandage  properly,  and  the  elevated  and  indurated 
edges  of  the  ulcer  will  be  absorbed,  and  the  ulcerated  surface  being 
supported  will  soon  begin  to  granulate,  and  when  the  granulations 
rise  as  high  as  the  surrounding  skin,  cicatrization  commences  usually 
at  the  edges,  but  sometimes  also  in  the  centre.  The  outer  layer  of 
the  lymph  is  converted  into  a  sort  of  epithelial  scales,  which  cover 
over  and  protect  the  subjacent  parts.  The  processes  of  cicatrization 
may  be  hastened  by  the  application  of  nitrate  of  silver,  applied  gently 


86  LECTUKES    ON    PRACTICAL    SURGERY. 

every  day  or  every  alternate  day  to  the  granulating  edges,  which  are 
sufficiently  elevated  to  render  cicatrization  possible.  Care  should  be 
taken  that  the  granulations  are  not  entirely  destroyed  by  the  appli- 
cation of  the  escharotic.  It  should  be  applied  so  gently  as  only  to 
cause  them  to  adhere,  so  as  to  favor  the  development  of  epithelial 
scales,  which  completes  the  process. 

Fig.  15,  before  exhibited,  represents  an  inflamed  ulcer;  the  edges  as 
you  will  perceive  are  covered  with  a  grayish  matter  which  cannot  be 
removed.  When  it  appears,  and  so  long  as  it  continues,  you  may  feel 
assured  that  the  ulcer  is  extending,  and  will  continue  to  extend  until 
its  character  is  changed.  The  inflammation  involves  the  entire  foot ; 
no  healthy  granulations  can  be  discovered,  and  the  color  presented 
is  produced  by  the  disintegration  of  the  surrounding  tissues.  The 
part  is  not  mortified,  but  the  disintegration  is  so  rapid  that  it  re- 
sembles it  very  closely.  Before  you  commence  the  treatment  of  an 
inflamed  ulcer,  you  should  endeavor  to  ascertain  whether  any  consti- 

FIG.  16. 


Acute  or  healthy  ulcer. 


tutional  derangement  exists  sufficient  to  account  for  the  local  diffi- 
culty, and  prescribe  the  treatment  calculated  to  meet  the  indication. 
The  patient  should  be  placed  in  a  horizontal  position,  and  the  foot 


LECTURE    VII.  —  ULCERATION.  87 

elevated  so  as  to  diminish  the  influx  of  blood.  The  water-dressing, 
poultices,  or  soft  cloths  wet  with  a  strained  decoction  of  poppy-heads 
should  be  applied,  and  covered  with  oiled  silk  so  as  to  prevent  evap- 
oration, and  the  whole  secured  by  the  application  of  a  bandage. 
Never  apply  a  solution  of  the  acetate  of  lead  to  an  ulcerated  surface. 
In  such  cases,  besides  the  constitutional  treatment  indicated,  the 
patient  must  be  kept  free  from  pain  by  McMunn's  elixir,  or  some 
other  preparation  of  opium,  or  the  anodyne  may  be  combined  with 
the  remedies  calculated  to  remove  the  constitutional  difficulty.  Such 
ulcers  occur  very  frequently  in  the  old  and  intemperate,  are  gener- 
ally located  on  the  lower  extremities,  and  are  always  exceedingly 
difficult  to  control. 

Fig.  16  represents  a  healthy  ulcer.  The  granulations  are  red, 
round,  and  not  very  large ;  they  are  even  with  the  skin,  and  the 
ulcer  is  in  a  condition  to  cicatrize  rapidly. 

Fig.  17  is  intended  to  present  the  appearance  of  an  old,  indolent, 

FIG.  17. 


Callous  ulcer. 


and  callous  ulcer;  the  granulations  are  large,  flabby,  and  pale.  The 
edges  are  elevated,  everted,  and  indurated,  but  sometimes  in  such 
cases  they  are  inverted. 

Fig.  18  is  intended  to  present  the  appearance  of  an  inflamed  ulcer 


88 


LECTURES  ON  PRACTICAL  SURGERY. 


produced  by  an  inverted  nail.  This  is  an  exceedingly  painful  and 
troublesome  difficulty,  and  can  only  be  relieved  by  elevating  the 
edge  with  forceps,  and  introducing  lint  wet  with  a  saturated  solution 
of  alum.  By  such  treatment  the  inflammation  is  controlled,  and  a 


Toe-nail  ulcer. 


recurrence  of  the  difficulty  prevented,  provided  the  treatment  is  con- 
tinued until  the  ulcer  cicatrizes,  and  the  nail  has  extended  beyond 
the  extremity  of  the  toe;  should  that  fail,  remove  the  inverted  nail 
with  the  matrix,  and  the  disease  cannot  recur. 

An  ulcer  will  cicatrize,  but  the  cicatrix  differs  from  the  natural 
integument.  It  is  a  fibro-cellular  substance,  is  less  vascular,  less 
sensitive,  and  differs  in  color  from  the  original  integument,  which  is 
never  reproduced. 

Ulcers  should  be  dressed  twice  a  day,  and  great  care  should  be 
taken  not  to  break  or  disturb  the  granulations.  Be  careful  to  keep 
the  dressings  so  wet  that  they  will  not  adhere  to  and  disturb  the 
process  of  cicatrization.  When  the  inflammation  has  been  con- 
trolled, simple  cerate  and  a  bandage  is  the  best  dressing  that  can  be 
made.  I  have  no  faith  in  the  efficacy  of  medicated  ointments; 


LECTURE    VII.  —  ULCERATION.  89 

they  should  only  be  applied  to  indolent  ulcers.  Generally  simple 
cerate  or  mutton  suet,  neither  of  which  will  irritate  the  granulating 
surface,  should  be  preferred.  When  a  stimulating  application  is 
needed,  the  basil  icon  or  citrine  ointment,  diluted  with  an  equal 
quantity  of  lard,  should  be  employed,  with  proper  constitutional 
treatment,  and  by  the  use  of  the  bandage  all  other  means  may  be 
dispensed  with.  Any  old  indolent  callous  ulcer  can  be  healed  by 
the  common  roller  bandage,  with  no  other  local  application  except 
mutton  tallow  or  simple  cerate.  Two  healthy  granulating  surfaces 
when  approximated  and  retained  in  contact  will  unite  as  certainly 
as  an  incised  wound.  A  case  has  recently  occurred  in  my  practice 
by  which  this  was  demonstrated.  A  gentleman  from  Stockton,  who 
was  in  feeble  heath,  had  an  epithelioma  removed  from  the  lower  lip. 
The  day  after  the  operation  he  had  a  paroxysm  of  intermittent  fever, 
which  prevented  union  by  the  first  intention;  the  sutures  were  al- 
lowed to  remain.  Sulph.  quinia3  was  administered  to  prevent  a 
recurrence  of  the  fever.  He  drank  a  bottle  of  porter  every  day, 
and  was  directed  to  take  as  much  nutritious  food  as  he  could  digest, 
and  in  one  week  the  union  was  as  complete  as  if  it  had  occurred 
by  the  first  intention. 

Sometimes  when  wounds  with  a  considerable  loss  of  substance 
heal,  the  cicatrix  is  so  contracted  as  not  only  to  produce  deformity, 
but  also  to  interfere  seriously  with  the  function  of  the  part.  The 
treatment  necessary  in  cases  of  that  character  will  be  hereafter  indi- 
cated. This  is  so  important  a  subject  that  a  concise  recapitulation 
will  not  be  unacceptable  to  the  class.  I  have  endeavored  to  render 
you  familiar  with  the  appearances  presented  by  the  ulcers  which  are 
not  disposed  to  heal. 

1st.  The  callous  ulcer  will  not  heal  in  consequence  of  defect  of 
action. 

2d.  The  irritable  or  inflamed  from  excessive  action. 

3d.  In  syphilitic  and  other  ulcers  from  peculiarity  of  action. 

1.  The  surface  of  an  ulcer  may  be  either  depressed  or  elevated. 

2.  They  may  be  inverted  or  everted  and  indurated. 

3.  The  discharge  may  be  purulent,  thin  and  ichorous,  bloody  or 
mixed. 

4.  The  adjacent  and  surrounding  parts  may  either  present  a  natu- 
ral appearance,  or  they  may  be  both  red,  swollen,  and  indurated. 

5.  Pain  depends  on  the  character  of  the  ulcer.     It  is  very  dis- 


90  LECTURES  ON  PRACTICAL  SURGERY. 

tressing  in  the  irritable  and  inflamed,  and  is  rarely  complained  of  in 
the  indolent. 

When  there  is  a  defect  of  action,  what  course  of  treatment  is  indi- 
cated? If  the  patient  be  old,  debilitated,  and  intemperate,  give 
tonics,  alteratives,  and  stimulants.  The  prescription  given  in  a 
previous  lecture,  composed  of  quinine,  rhubarb,  sanguinaria  Cana- 
densis,  and  cicuta,  may  be  given  with  porter,  wine,  or  any  other 
stimulant  in  moderate  quantity  after  meals,  especially  if  the  patient 
has  been  accustomed  to  excessive  stimulation. 

In  the  constitutional  treatment  the  improvement  of  the  general 
health  should  receive  your  especial  attention ;  this  should  never  be 
neglected,  for  if  it  be  not  improved,  the  best-directed  local  treatment 
will  fail.  Always  dress  an  ulcer  so  that  the  secretion  can  escape  as  fast 
as  it  is  formed ;  consequently  you  should  never  apply  dry  lint  either  to 
a  wound  or  ulcer,  because  it  will  adhere  to  the  surface  and  prevent 
the  escape  of  the  purulent  secretion,  which  will,  when  a  considerable 
accumulation  takes  place,  make  sufficient  pressure  to  produce  an 
absorption  of  the  granulations  for  its  accommodation. 

If  lint  be  applied  it  should  be  wet,  and  the  moisture  retained  by 
the  application  of  oiled  silk.  Always  apply  a  dressing  that  will 
neither  irritate  nor  adhere  to  the  surface  of  an  ulcer.  You  may  use 
simple  cerate,  mutton  tallow,  glycerin,  or  chalk  ointment,  it  is 
immaterial  which,  if  it  fulfils  the  indication.  After  an  ulcerated 
surface  has  been  cleansed  and  any  of  the  articles  enumerated  ap- 
plied, then  wet  a  common  roller  bandage  either  with  water  or 
diluted  alcohol,  and  apply  it  firmly  but  smoothly  from  instep  to 
knee.  When  dressed  in  that  manner  every  day  I  cannot  imagine 
an  ulcer  that  will  not  heal.  Pressure  is  more  important  in  the 
treatment  of  such  cases  than  all  the  other  local  remedies  combined. 
Bay n ton  recommended  adhesive  strips  applied  in  such  a  manner  as 
to  support  the  granulations.  Cures  have  unquestionably  resulted 
from  their  employment,  but  no  one  who  can  apply  a  bandage  would 
ever  think  of  substituting  adhesive  strips.  They,  are  more  trouble- 
some, and  are  liable  to  the  objection  made  against  the  use  of  dry  lint 
as  a  dressing  in  such  cases.  The  secretion  is  confined,  and  if  abun- 
dant, as  it  cannot  escape,  the  ulcer  instead  of  healing  will  become 
daily  more  extensive. 

Ulcers  with  excessive  action  require  very  different  treatment,  as 
pressure  cannot  be  advantageously  applied.  The  patient  should  be 


LECTURE    VII.  —  TREATMENT    OF    ULCERS.  91 

placed  in  a  recumbent  position,  and  every  means  adopted  calculated 
to  quiet  both  the  constitutional  and  local  disturbances.  Depressants 
combined  with  opium,  if  the  pain  be  distressing,  will  accomplish  the 
former.  Never  allow  a  patient  to  suffer  pain  or  pass  a  sleepless 
night,  for  you  cannot  diminish  the  vascularity  of  an  ulcer  so  long 
as  the  pain  continues.  In  the  latter  I  have  already  advised  the  or- 
dinary remedies;  sometimes  they  all  fail.  The  ulcerated  surface 
becomes  more  and  more  painful,  a  diphtheritic  deposit  takes  place, 
accompanied  with  a  profuse  acrid  and  offensive  discharge.  I  have 
met  with  five  or  six  cases  of  this  character,  and  recently  two  oc- 
curred in  one  family  as  a  sequence  of  scarlatina.  In  one  the  ulcer 
was  produced  by  the  application  of  a  small  blister,  which  was  em- 
ployed to  denude  a  surface  for  the  purpose  of  applying  the  sulphate 
of  morphia  to  relieve  a  pain  in  the  left  side  of  the  chest.  Instead 
of  healing  as  usual,  it  became  excessively  painful,  and  soon  presented 
the  appearance  described.  It  resisted  the  action  of  the  usual  remedies, 
and  I  became  convinced  that  if  relief  was  not  speedily  afforded,  the 
general  health  must  suffer  from  the  pain  and  the  quantity  of  opium 
which  it  was  found  necessary  to  administer ;  I  therefore  determined 
to  apply  the  nitrate  of  silver,  the  patient  being  under  the  influence 
of  chloroform.  It  was  applied  in  a  solid  form  effectually  two  days 
in  succession ;  flaxseed  poultices  were  applied  until  the  slough  was 
detached.  The  surface  of  the  ulcer  was  then  covered  every  day 
with  the  subnitrate  of  bismuth,  and  protected  by  the  water-dressing 
until  it  cicatrized. 

In  the  other  case  the  ulcer  resulted  from  a  small  portion  of  the 
cuticle  being  detached  from  the  second  joint  of  the  middle  finger. 
It  spread  so  rapidly  and  its  progress  was  accompanied  by  so  much 
pain  that  I  became  exceedingly  solicitous  for  the  safety  of  the  finger. 
The  same  local  treatment  with  suitable  constitutional  remedies  were 
prescribed  and  with  a  similar  result. 

When  irritable  ulcers  continue  to  enlarge  in  spite  of  the  treatment 
adopted,  they  are  called  phagedenic,  and  when  the  skin  and  subcu- 
taneous cellular  tissues  lose  their  vitality,  sloughing  ulcers.  When 
chancres  are  neglected  or  improperly  treated,  the  parts  frequently 
slough  with  fearful  rapidity,  the  entire  organ  being  sometimes  de- 
stroyed in  forty-eight  hours. 

When  an  ulcer  heals  at  one  point  and  appears  at  another  it  is 
called  serpiginous ;  we  very  often  meet  with  syphilitic  ulcers  which 


92  LECTURES  ON  PRACTICAL  SURGERY. 

present  that  peculiarity.  The  only  remedy  which  I  have  found 
effective  to  change  the  action  and  arrest  their  progress  is  nitric  acid. 
It  should  be  repeated  every  three  or  four  days  until  the  desired  effect 
is  produced. 

When  an  ulcer  resists  all  treatment  it  is  called  a  cancer,  and  then 
all  that  can  be  expected  from  medical  treatment  is  to  relieve  the  pain, 
and  by  the  use  of  opium  to  render  the  condition  of  the  patient  sup- 
portable. Ulcers  which  do  not  heal  from  a  peculiarity  of  action  may 
result  from  derangement  of  the  digestive  organs,  suppression  of  the 
catamenia,  a  scrofulous  diathesis,  or  constitutional  syphilis.  In  all 
the  varieties  of  ulcer,  the  local  treatment  should  depend  upon  the 
stage  and  condition,  and  the  constitutional  remedies  should  be  adapted 
to  the  constitution  of  the  patient,  and  the  cause  by  which  the  local 
difficulty  has  been  produced,  which  will  hereafter  be  considered. 

There  are  other  peculiarities  of  ulcers  with  which  you  should  be 
familiar.  The  surface  of  an  ulcer  may  be  either  depressed  or  ele- 
vated. When  an  ulcerated  part  is  kept  in  a  horizontal  position  long 
enough  for  granulations  to  appear,  whether  they  be  healthy  or  other- 
wise, the  surface  of  the  ulcer  very  soon  becomes  elevated  above  the 
surrounding  integument.  But  should  it  be  placed  in  a  dependent 
position  without  support,  the  granulations  are  destroyed,  and  the 
surface  is  depressed.  In  indolent  ulcers,  particularly  upon  the  lower 
extremities,  the  edges  are  always  indurated,  and  may  be  either  in- 
verted or  everted.  This  peculiarity,  however,  will  disappear  in  a 
few  days  by  the  use  of  the  bandage,  and  of  internal  remedies  calcu- 
lated to  remove  the  constitutional  derangement. 

Pain. — We  have  already  said  that  the  pain  depends  on  the  irrita- 
bility of  the  patient  and  the  degree  of  local  inflammation.  Some- 
times the  surrounding  and  adjacent  parts  become  thickened  and 
indurated,  with  but  little  redness,  but  in  irritable  ulcers,  the  redness 
corresponds  with  the  violence  of  the  local  action,  and  the  pain  it 
produces. 

The  discharge  from  ulcers  differs  as  greatly  as  they  do  in  appear- 
ance. You  should  expect  the  secretion  from  a  healthy  ulcer  to  be 
what  is  called  laudable  pus,  which  has  been  already  described.  From 
an  ulcer  with  defect  of  action,  a  thin  offensive  fluid  escapes,  resem- 
bling a  mixture  of  serum  with  unhealthy  purulent  matter.  From 
an  irritable  or  inflamed  ulcer,  bloody  serum,  which  does  not  present 
the  slightest  resemblance  to  the  discharge  that  should  be  secreted  by 


LECTURE    VII.  —  INDURATION.  93 

a  healthy  granulating  surface.  Always  examine  the  discharge  from 
an  ulcer  before  you  express  an  opinion  respecting  its  character  and 
curability.  When  an  ulcer  has  existed  for  several  years,  is  it  good 
surgery  to  heal  it,  even  if  it  be  possible?  Unless  the  patient  be 
scrofulous,  if  the  ulcer  be  located  upon  the  extremities,  I  think  it  is 
always  safe,  provided  the  bowels  be  kept  free  by  the  use  of  laxatives. 
Three  years  ago  I  cured  an  ulcer  on  the  leg  larger  than  my  hand,  that 
had  been  discharging  for  more  than  twenty  years.  The  leg  was 
enormously  enlarged,  and  the  discharge  was  profuse.  By  the  use  of 
the  bandage  and  laxatives,  the  limb  was  reduced  to  its  normal  size, 
and  the  ulcer  healed,  with  a  decided  improvement  of  the  general 
health. 

In  a  previous  lecture  I  endeavored  to  describe  the  textural  changes 
that  result  from  inflammation,  and  will  allude  to  them  in  this  lec- 
ture. 

Ramollissement  or  Softening,  both  Acute  and  Chronic. — The  latter 
occurs  more  frequently  in  the  brain,  the  mucous  membrane  of  the 
stomach  and  bowels ;  the  former  in  the  lungs,  spleen,  liver,  and 
heart.  I  have,  however,  occupied  as  much  of  your  attention  on 
this  subject  as  the  time  allowed  me  will  permit,  and  will  speak  of 
induration,  which  results  from  the  effusion  and  organization  of 
lymph. 

The  organs  most  liable  to  induration  are  the  lungs,  spleen,  liver, 
thyroid  gland,  testicles,  ovaries,  lymphatic  ganglions,  and  bones. 
We  have  now  in  the  hospital  a  case  of  induration  and  enlargement 
of  the  thyroid  gland.  There  are  other  organs  which  may  also 
become  indurated,  as  the  subcutaneous  cellular  tissue  and  prostate 
gland,  particularly  in  advanced  age.  This  is  very  liable  to  enlarge- 
ment and  induration,  which  gives  great  inconvenience,  because  it 
renders  the  passage  of  urine  not  only  difficult  but  sometimes  impos- 
sible. 

Enlargement  of  the  spleen  and  liver,  when  produced  by  repeated 
attacks  of  intermittent  fever,  yields  almost  always  to  the  combined 
influence  of  quinine,  rhubarb,  sanguinaria  Canadensis,  and  cicuta. 
The  quinine  and  sanguinaria  Canadensis  prevent  the  recurrence  of 
the  fever,  and  in  combination  with  the  other  ingredients,  will  remove 
the  enlargement  by  increasing  the  biliary  secretion,  and  improving 
the  general  health..  I  have,  both  in  California  and  elsewhere,  wit- 


94  LECTURES  ON  PRACTICAL  SURGERY. 

nessed  the  most  extraordinary  effects  from  this  combination.  I  have 
known  the  sanguinaria  alone  to  remove  an  enormous  enlargement 
of  the  spleen,  and  prevent  the  recurrence  of  intermittent  fever  by 
which  it  was  produced,  in  a  few  weeks,  after  it  had  resisted  the  treat- 
ment of  the  best  physician  in  the  vicinity.  Being  struck  by  its 
effect  in  that  case,  I  combined  it  with  quinine,  rhubarb,  and  cicuta, 
and  from  long  experience  have  been  convinced  of  its  great  efficacy, 
and  that  that  combination  is  superior  to  any  other,  not  only  to  pre- 
vent the  recurrence  of  intermittent  fever,  but  also  to  remove  the 
indurations  of  the  spleen  and  liver  which  it  produces. 

The  next  subject  which  presents  itself  is  transformation,  of  which 
there  are  four  varieties  : 

1st.  The  cellular,  as  in  the  thymus  gland  and  capsular  ligament. 

2d.  The  fibrous,  as  found  in  the  arteries  and  veins. 

3d.  Calcareous,  in  the  arteries  and  joints. 

4th.  The  fatty,  in  the  arteries,  heart,  liver,  etc. 

The  thymus  gland  in  infancy  is  quite  large ;  it  is  located  near  the 
upper  extremity  of  the  sternum,  and  after  birth  it  diminishes  grad- 
ually in  size  until  it  almost  entirely  disappears,  which  is  called 
transformation. 

Fibrous  transformation  occurs  in  the  coats  of  an  artery  after  it  has 
been  ligated,  between  the  point  occupied  by  the  ligature  and  the  first 
large  branch  above ;  all  the  coats  undergo  that  change.  The  same 
change  takes  place  in  the  veins  when  the  circulation  is  obstructed 
by  the  use  of  pins  or  otherwise,  as  in  the  operation  for  varicocele. 

The  third  variety  is  the  calcareous.  This  occurs  very  frequently 
in  the  arteries  of  old  people,  but  it  is  sometimes  met  with  in  persons 
who  have  not  reached  middle  age.  Three  years  ago  I  treated  a  con- 
sumptive patient,  28  years  old,  in  the  St.  Mary's  Hospital,  and  found 
that  every  superficial  artery  had  undergone  that  change,  which  is 
easily  detected  by  the  diminution  in  the  volume  as  well  as  by  the  in- 
duration and  irregularity  of  the  vessel.  I  have  from  observation  been 
induced  to  believe  that  intemperance  favors  or  predisposes  to  this 
transformation.  The  first  case  of  this  character  which  I  had  an  op- 
portunity of  examining  carefully,  I  found  in  my  dissecting-room 
about  twenty  years  ago.  The  young  man  had  died  in  the  lunatic  asy- 
lum. He  had  been  paralyzed  for  several  years,  and  it  was  found  to 
be  impossible  to  dissect  his  body  in  consequence  of  every  bloodvessel 


LECTURE  VII.  —  FATTY  DEGENERATION.          95 

having  undergone  calcification.     A  quiescent  or  inactive  state  may 
also  favor  the  deposition  of  calcareous  matter. 

Fatty  degeneration  occurs  more  frequently  than  the  calcareous, 
and  its  consequences  are  also  more  serious.  The  heart,  liver,  and 
bloodvessels  suffer  more  frequently  from  this  difficulty  than  the 
other  important  organs  of  the  body. 

This  liability  of  the  bloodvessels  to  fatty  degeneration  will  account 
for  the  extraordinary  number  of  deaths  which  occur  from  aneurism, 
both  in  California  and  on  the  entire  Pacific  coast. 

Fatty  transformation  of  the  heart  and  liver  are  both  very  common, 
if  we  can  rely  upon  the  certificates  of  death  found  in  the  health 
office  of  this  city.  The  unexceptionable  prosperity  of  our  liquor 
merchants  will  suggest  the  cause.  When  that  difficulty  occurs  the 
affected  organ  presents  too  pale  an  appearance,  and  is  diminished 
both  in  size  and  consistence,  which  when  the  heart  is  implicated 
becomes  very  serious,  because  it  soon  is  incapable  to  perform  its 
function.  When  fatty  transformation  takes  place  in  the  liver,  the 
organ  diminishes  in  size,  becomes  pale,  the  granulated  appearance 
is  changed  into  a  grayish  mass,  and  very  soon  the  eyes  and  skin 
present  a  yellowish  or  leaden  appearance,  cerebral  symptoms  are 
presented,  and  the  scene  is  speedily  closed. 

This  is  a  disease  of  a  very  serious  character,  and  the  question  now 
arises,  can  it  be  prevented,  and  by  what  means  can  it  be  arrested 
after  it  has  occurred  ?  Professional  experience  has  been  barren  of 
useful  results,  but  the  advice  I  should  give  in  order  to  avoid  its  devel- 
opment is  to  take  sufficient  exercise,  live  temperately,  and  you  have 
little  to  fear  from  fatty  transformation  or  degeneration.  Hypertro- 
phy or  an  increase  of  magnitude  is  not  uncommon,  and  occurs  more 
frequently  in  the  heart  and  thyroid  gland  than  elsewhere.  It  may 
be  either  partial  or  general.  It  results  from  the  deposition  and  or- 
ganization of  plastic  lymph,  and  the  tissue  thus  produced  resembles 
that  of  which  the  organ  was  originally  composed  ;  it  is  consequently 
called  analogous.  It  increases  in  magnitude  without  presenting 
other  evidences  of  disease.  The  causes  are  inordinate  exertion,  vas- 
cular obstruction,  and  chronic  inflammation.  The  porters  in  Paris, 
who  carry  enormous  loads,  are  very  subject  to  hypertrophy  of  the 
heart;  cases  are  met  with  in  all  the 'hospitals  of  that  city,  and  it  is 
not  necessarily  connected  either  with  valvular  derangement  or  dis- 


LECTURES    ON    PRACTICAL    SURGERY. 

ease  of  the  arteries.  When  the  venous  circulation  is  disturbed,  as 
in  a  varicose  condition  of  the  veins  of  the  lower  extremities,  the 
parietes  of  the  vessels  become  thickened,  distended,  and  greatly 
elongated,  and  even  when  obstructed  by  an  operation  never  present 
a  normal  appearance. 

After  the  subsidence  of  chronic  inflammation,  the  part  affected 
may  never  resume  its  original  size  and  appearance,  although  it  may 
be  perfectly  healthy.  Atrophy  or  shrinking  may  result  either  from 
want  of  exercise,  from  loss  of  nervous  influence,  or  from  inflammation. 
Should  the  arm  of  a  healthy  man  be  carried  in  a  sling  for  three  or  four 
months,  the  muscles  will  be  so  much  atrophied  as  to  lose  almost  en- 
tirely their  contractile  power.  Loss  of  nervous  influence  is  followed 
by  the  same  result.  I  am  familiar  with  a  case  of  this  character.  A 
gentleman  had  his  right  shoulder  severely  injured,  which  was  followed 
by  inflammation  of  the  joint  and  the  adjacent  parts.  When  the  in- 
flammation disappeared  it  was  found  that  the  power  of  the  forefinger 
and  thumb  was  almost  entirely  lost,  and  the  sensibility  of  the  other 
three  fingers  was  destroyed,  without  the  power  of  the  muscles  being  in 
the  slightest  degree  impaired.  The  difficulty  no  doubt  resulted  from 
the  pressure  which  was  made  by  the  effusion  and  organization  of 
lymph  during  the  existence  of  the  inflammation,  and  yielded  slowly 
to  the  application  of  counter-irritants  to  the  shoulder,  combined  with 
moderate  but  constant  exercise. 

Atrophy  may  also  result  from  inflammation,  and  it  is  especially 
liable  to  follow  that  produced  in  the  testis  by  the  metastasis  which 
frequently  occurs  in  mumps.  When  that  gland  has  become  atro- 
phied under  such  circumstances,  it  is  useless  to  annoy  the  patient  by 
prescribing  remedies  from  which  he  can  derive  no  benefit. 

A  few  remarks  upon  contraction  and  obliteration  will  finish  this 
lecture.  The  former  frequently  results  from  the  cicatrization  of 
wounds,  from  which  considerable  Joss  of  tissue  has  been  sustained, 
especially  in  cases  of  extensive  burns.  The  contraction  frequently 
increases  for  some  time  after  the  wound  has  cicatrized.  Thus  the 
under  lip  may  be  drawn  down  so  much,  that  it  is  impossible  to  con- 
ceal the  teeth.  When  the  contraction  is  so  great  and  extensive,  it  is 
impossible  to  afford  relief  even  by  the  most  skilful  plastic  operation. 
When  less  extensive,  the  deformity  may  be  entirely  removed  by  a 
procedure  that  will  be  described  in  a  subsequent  lecture. 


LECTURE    VII.  —  CONTRACTION    IN    HEALING.  97 

The  canals  or  outlets  of  the  body,  which  are  lined  by  a  mucous 
membrane,  may  become  contracted,  and  produce  the  disease  called 
stricture,  which  will  hereafter  receive  especial  attention. 

Fistula  may  be  included  in  this  lecture,  from  its  connection  with 
diseases  of  the  mucous  membrane.  A  fistula  is  a  narrow,  straight 
or  tortuous  danal,  with  one  or  more  openings,  which  secretes  a  fluid, 
and  may  be  located  upon  any  portion  of  the  body,  but  appears 
generally  in  the  groin,  on  the  neck,  or  near  the  anus ;  it  frequently 
originates  from  carious  bone,  a  diseased  lymphatic  ganglion,  or  from 
pulmonary  disease,  which  it  is  intended  to  palliate. 


98  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   VIII. 

I 

THE  subject  of  the  present  lecture  is  congenital  malformations, 
which  are  exceedingly  important  and  should  be  well  understood. 

They  consist  first  of  a  deficiency  of  parts,  which  includes  fissures 
as  well  as  entire  absence. 

Fissures  are  most  common ;  they  embrace  harelip,  fissure  of  the 
palate,  epispadias,  hypospadias,  spina  bifida,  and  enlargement  of  the 
fontanelles.  In  epispadias  there  is  not  only  a  deficiency,  but  also 
a  malposition  of  parts.  The  urethra  not  only  terminates  before 
reaching  the  extremity  of  the  corpora  cavernosa,  but  also  is  found 
upon  the  upper  side  of  the  penis,  and  directly  below  the  symphysis 
pubis,  and  beyond  that  point  the  urethra  does  not  extend.  In  hy- 
pospadias, which  is  much  more  common,  the  urethra  may  open  in 
front  of  the  scrotum,  or  at  any  point  posteriorly  to  its  base.  Some- 
times there  is  a  complete  division  of  the  scrotum  between  the  tes- 
ticles. 

Epispadias  I  believe  to  be  incurable.  It  occurs  so  rarely  that  I 
have  never  had  an  opportunity  of  performing  an  operation  in  such  a 
case,  and  indeed  I  think  it  could  not  be  successfully  done. 

Hypospadias. — This  deformity  may  under  favorable  circumstances 
be  cured.  I  operated  two  years  since  upon  twins  under  very  un- 
favorable circumstances,  and  from  the  result  obtained  I  have  arrived 
at  that  conclusion. 

The  patient  should  be  placed  upon  the  back,  with  the  hands  and 
feet  secured  as  in  an  operation  for  stone.  A  flexible  catheter  should 
be  introduced,  and  retained  in  the  bladder  for  at  least  a  week,  after 
the  operation  has  been  performed. 

The  cuticle  is  first  removed  from  the  opposite  sides  of  the  fissure, 
sufficiently  far  from  the  centre,  so  that  when  the  denuded  surfaces 
are  placed  in  contact,  the  catheter  can  be  covered  without  so  much 
traction  being  made  as  to  endanger  the  vitality  of  the  skin,  and  di- 
minish the  prospect  of  union  by  the  first  intention. 

When  approximated  the  denuded  surfaces  should  be  kept  in  con- 
tact by  the  interrupted  silver  suture,  which  should  be  allowed  to 


LECTURE    VIII.  —  CONGENITAL    DEFICIENCIES.  99 

remain  at  least  ten  days,  so  that  if  union  by  the  first  intention  should 
fail,  it  may  occur  by  granulation.  In  such  cases  it  is  almost  impos- 
sible to  succeed  in  removing  the  entire  difficulty  by  one  operation, 
particularly  in  children.  In  some  cases  after  union  has  taken  place, 
in  consequence  of  a  constitutional  peculiarity,  the  presence  of  the 
sutures  may  produce  inflammation  sufficient  either  partially  or  en- 
tirely to  destroy  the  bond  of  union,  and  subject  you  to  the  necessity 
of  repeating  the  operation. 

Enlargement  of  the  fontanelles  is  a  very  common  difficulty,  and 
for  that  reason  it  is  mentioned  so  that  you  may  know  what  advice  to 
give  in  such  cases.  Such  children  always  present  a  delicate  appear- 
ance. The  head  is  unnaturally  large,  and  the  fontanelles  as  well  as 
the  sutures  unusually  open.  Such  cases  do  not  require  local  treat- 
ment, but  in  consequence  of  the  arrest  of  osseous  development,  the 
remedies  calculated  to  improve  the  general  health  should  be  pre- 
scribed. Three  or  four  half-grain  doses  of  calomel  at  night  may  be 
given  to  produce  a  healthy  action  of  the  liver,  which  should  be  fol- 
lowed by  the  precipitated  carbonate  or  phosphate  of  iron,  or  Que- 
venne's  iron,  combined  with  the  fluid  ext.  of  senna  if  a  laxative  be 
necessary,  and  either  the  tincture  of  nux  vomica,  quinine,  or  the 
subcarb.  of  bismuth,  according  to  the  indications  of  the  ease  under 
treatment. 

Absence  of  Structures. — Sometimes  there  is  an  entire  deficiency  of 
important  parts.  About  a  year  ago  I  delivered  a  patient  of  a  child 
that  had  neither  hands  nor  feet.  The  superior  extremities  were  de- 
ficient from  the  middle  of  the  forearm,  and  the  lower  from  the  centre 
of  the  thighs.  The  inferior  maxillary  bone  and  the  tongue  were 
both  unnaturally  small,  although  the  infant  was  able  to  take  suffi- 
cient nourishment  from  the  breast  not  only  to  live,  but  also  to  enjoy 
good  health  for  eight  months,  when  he  died  of  cholera  infantum. 

Recently  I  delivered  a  monster  both  in  size  and  shape.  The  knee 
and  elbow-joints  were  anchylosed,  and  the  arms  and  legs  turned  di- 
rectly inward.  The  same  defect  existed  in  the  tongue  and  inferior 
maxillary  bone  which  has  already  been  described.  The  child  weighed 
sixteen  pounds,  remained  in  the  uterus  eleven  months,  and  was  de- 
livered with  greater  difficulty  than  I  ever  before  experienced,  except 
when  deformity  of  the  pelvis  existed.  The  child  was  born  alive, 
but  the  respiration  being  difficult  in  consequence  of  the  contraction 
of  the  respiratory  muscles,  it  fortunately  lived  only  a  few  days.  Any 


100 


LECTURES    ON    PRACTICAL    SURGERY. 


portion  of  the  body  may  be  absent,  and  it  is  unnecessary  to  enumer- 
ate all  the  cases  of  this  character  that  have  been  reported.  Super- 
numerary parts  are  met  with  frequently.  Sometimes  a  child  is  born 
with  an  extra  finger,  and  it  is  almost  always  attached  to  the  external 
side  of  the  little  finger,  near  its  junction  with  the  hand.  I  have 
seen  the  thumb  double,  with  two  bones  and  distinct  and  separate 
nails.  The  supernumerary  part  must  always  be  removed,  but  you 
should  invariably  wait  until  the  period  of  dentition  has  passed,  and 
the  general  health  is  good.  This  course  should  be  observed  when 
the  fingers  adhere,  or  a  distinct  articulation  exists.  When  the  at- 
tachment is  small  and  composed  only  of  the  integument,  it  may  be 
removed  early  without  the  least  apprehension  of  any  serious  conse- 
quence resulting.  Never  perform  either  this  or  any  other  operation 
that  can  be  postponed  when  erysipelas  is  prevalent. 

Harelip. — In  order  that  you  may  understand  what  the  word  hare- 
lip means,  I  have  had  drawings  made  which  will  represent  every 
variety  of  this  common  and  exceedingly  unpleasant  deformity. 

Fig.  19  represents  the  simplest  form  of  the  disease,  a  mere  fissure 


FIG.  19. 


FIG.  20. 


which  extends  only  to  the  nostril,  and  there  is  no  defect  either  of  the 
superior  maxillary  bone  or  soft  palate. 

In  Fig.  20  you  see  what  is  called  a  double  harelip,  there  being  a 
fissure  in  each  side,  and  this  variety  may  be  either  simple  or  compli- 
cated with  a  fissure  of  both  the  hard  and  soft  palates. 


LECTURE    VIII.  —  HARELIP.  101 

In  some  cases  there  is  not  only  a  defect  of  the  palate,  but  a  fissure 
exists  on  each  side,  generally  uniting  at  about  the  centre  of  the  hard 
palate.  In  such  cases  what  remains  of  the  upper  lip  projects  from 
the  superior  extremity  of  the  nose.  The  difficulty  experienced  in 
their  treatment  is  to  close  the  fissure  in  such  a  manner  that  a  notch 
will  not  remain,  which  is  always  an  unmistakable  evidence  that  an 
operation  of  that  character  has  been  performed. 

The  operation  in  simple  harelip  consists  in  paring  off  the  edges 
either  with  a  scalpel  or  scissors,  and  approximating  and  retaining 
them  in  contact,  either  by  the  harelip  pins  and  the  figure-of-eight 
suture,  or  by  the  interrupted  silver  suture,  which  I  think  is  superior 
to  the  former. 

I  have  always  found  it  necessary,  in  order  to  retain  the  edges  of  the 
lip  in  perfect  apposition,  to  insert  a  small  silk  suture,  which  may  be 
removed  the  third  day ;  but  the  needles  or  silver  sutures  should  be 
allowed  to  remain  six  or  seven  days,  because  they  give  no  inconveni- 
ence, and  by  pursuing  that  course  a  failure  is  impossible.  When 
the  ala3  of  the  nose  are  greatly  separated,  and  drawn  downwards, 
they  should  be  detached  and  placed  in  their  proper  position.  The 
best  operation  for  harelip,  and  the  only  one  that  can  be  performed 
by  which  the  deformity  is  entirely  removed,  is  as  follows : 

The  mucous  membrane  on  one  side  is  preserved,  and  removed  from 
the  other,  so  that  when  the  edges  are  approximated,  it  can  be  drawn 
across  so  as  to  prevent  a  fissure  at  the  point  of  union.  It  should  be 
secured  by  a  suture  composed  of  a  single  thread  of  fine  silk. 

When  two  fissures  exist,  the  edges  of  the  centre  piece  should  be  re- 
moved so  that  they  may  unite  with  the  corresponding  portions  of  the 
lip  on  each  side.  A  curved  needle  should  be  inserted  about  half  an 
inch  from  the  edge  of  the  lip  on  one  side,  passed  down  to  the  mucous 
membrane,  through  the  centre  portion  and  the  lip  on  the  opposite 
side,  in  the  manner  already  described.  Three  sutures  are  all  that  are 
necessary  even  in  the  most  aggravated  case.  Should  the  centre  por- 
tion be  short,  the  deficiency  can  be  supplied  by  drawing  a  portion  of 
the  mucous  membrane  across,  and  attaching  it  to  the  opposite  side. 
I  performed  this  operation  successfully  a  few  days  since  in  a  case 
that  appeared  very  unpromising. 

If  a  child  be  able  to  nurse,  I  would  not  advise  an  operation  to  be 
performed  before  the  fifth  or  sixth  month.  If  the  deformity  be 
so  great  as  to  interfere  with  nutrition,  then  the  operation  should  be 


102  LECTURES    ON    PRACTICAL    SURGERY. 

performed  within  the  first  week.  Always  be  careful  not  to  allow 
the  patient  to  lose  much  blood.  It  would  be  better  to  apply  a  small 
ligature  to  every  bleeding  vessel  than  to  incur  the  risk  of  haemor- 
rhage, either  primary  or  secondary. 

The  third  variety  mentioned  is  exceedingly  complicated :  the  upper 
lip  is  deficient ;  the  teeth  are  exposed,  and  there  is  a  projection  from 
the  end  of  the  nose,  and  a  deficiency  exists  both  in  the  hard  and  soft 
palate.  The  deformity  in  these  cases,  unpromising  as  they  appear, 
can  be  entirely  removed.  In  the  first  place  dissect  up  from  the  bone 
the  superior  portion  of  the  lip  on  each  side,  with  the  alse  of  the  nose; 
remove  with  forceps  the  plate  of  bone  that  sustains  the  teeth  di- 
rectly backward  on  a  line  with  the  septum  of  the  nose ;  reduce  the 
size  of  the  projection  from  its  extremity,  so  as  to  form  a  septum, 
turn  it  down  and  secure  it  in  that  position  by  passing  the  first  suture 
through  it,  which  is  intended  to  bring  the  edges  of  the  lip  together. 
After  the  removal  of  the  teeth,  and  the  formation  of  the  septum,  they 
can  be  approximated  and  retained  in  contact  as  easily,  and  as  little 
deformity  will  result,  as  from  an  operation  for  the  simplest  variety 
of  harelip.  When  the  fissure  extends  through  both  the  hard  and 
soft  palate,  that  in  the  former  may  be  closed  by  constant  and  mod- 
erate pressure  made  upon  both  sides  of  the  superior  maxillary  bone. 

FIG.  21. 


Dupuytren's  instrument  consists  of  two  small  pads  connected  with 
a  bandage  half  an  inch  in  width  that  passed  over  the  upper  lip,  and 
was  secured  by  a  buckle  behind,  and  retained  in  the  proper  position 
by  a  strap  which  passed  over  the  head. 


LECTURE    VIII.  —  FISSURE    OF    THE    PALATE.  103 

The  shape  of  the  bones  of  young  persons  can  be  easily  changed. 
The  best  illustration  I  can  give  is  afforded  by  the  Flathead  Indians 
of  Oregon.  Soon  after  birth  a  thin  smooth  piece  of  wood  four  or 
five  inches  in  width  is  applied  to,  and  secured  upon,  both  the  ante- 
rior and  posterior  portions  of  the  head,  and  the  application  is  con- 
tinued until  the  fontanelles  close,  and  the  cranium  by  a  bilateral  de- 
velopment has  assumed  the  shape  desired.  This  is  accomplished 
without  giving  the  child  much  inconvenience.  The  position  of  the 
bones  of  the  face  can  be  changed  with  equal  certainty  by  constant 
and  moderate  pressure. 

A  fissure  of  the  soft  palate  is  an  exceedingly  unpleasant  difficulty, 
as  it  always  impairs  the  voice,  and  sometimes  interferes  seriously  with 
deglutition. 

It  was  considered  incurable  until  Roux  practically  demonstrated 
that  it  was  as  amenable  to  surgical  treatment  as  any  other  deformity. 
The  operation  required  in  such  cases  is  called  staphylorraphy,  and 
consists,  as  in  harelip,  in  paring  off  the  edges  of  the  fissure,  and  in 
lacing  and  retaining  them  in  contact  by  the  interrupted  silver  su- 
ture until  union  takes  place. 

The  patient  should  be  placed  before  a  window,  and  whilst  the 
tongue  is  pressed  down  by  an  assistant,  one  edge  of  the  fissure  should 
be  seized  with  long  delicate  forceps,  and  removed  either  with  a  sharp 
scalpel  or  bistoury.  I  have  frequently  removed  the  mucous  mem- 
brane from  both  sides  of  the  fissure  without  changing  the  position  of 
the  forceps.  The  sutures  may  be  placed  either  before  or  after  the 
edges  have  been  removed,  and  a  small  curved  needle  secured  by 
Roux's  porte-aiguille,  the  one  invented  by  Sims,  and  found  in  his 
case,  or  that  which  I  will  hereafter  exhibit,  which  I  directed  Mr. 
Volkers,  of  this  city,  to  make  for  this  operation  as  well  as  that  for 
vesico-vaginal  fistula.  The  points  of  suture  should  be  about  half 
an  inch  apart,  and  when  the  uvula  is  involved,  a  single  thread  of 
silk  should  be  preferred  to  retain  the  edges  in  contact,  as  its  presence 
will  be  less  inconvenient  to  the  patient.  Should  any  difficulty  be 
experienced  in  approximating  the  edges  in  consequence  of  a  deficiency 
of  the  parts,  two  lateral  incisions  should  be  made  so  as  to  lessen  the 
tension,  and  remove  the  possibility  of  a  failure  by  strangulation. 

So  long  as  it  is  necessary  to  allow  the  sutures  to  remain,  solid  food 
should  be  prohibited.  Operations  of  this  character  usually  require 
both  patience  and  considerable  manual  dexterity.  Sometimes  you 


104  LECTURES    ON    PRACTICAL    SURGERY. 

will  find  a  case  in  which  no  difficulty  will  be  experienced.  The 
first  operation  I  performed  was  completed  in  sixteen  minutes,  and  I 
have  sometimes  found  it  impossible  to  complete  it  in  less  than  an 
hour.  Even  Roux,  who  was  one  of  the  best  operators  in  Paris,  was 
sometimes  an  hour  in  performing  this  operation.  In  a  case  of  extreme 
difficulty  upon  which  he  operated  before  the  class,  the  mouth  was 
small,  the  maxillary  bones  very  long,  and  there  existed  apparently 
a  morbid  sensibility  which  caused  an  effort  to  vomit  to  result  from 
even  touching  the  palate  with  instruments.  I  succeeded  in  two 
cases  in  this  city  in  which  the  mucous  membrane  and  palate-bones 
were  both  destroyed,  leaving  an  opening  an  inch  long  and  half  an 
inch  in  width  without  involving  the  soft  palate.  After  the  edges 
were  removed  and  the  sutures  inserted,  lateral  incisions  were  made, 
and  the  mucous  membrane  that  intervened  between  them  and  the 
fissure  was  detached  from  the  bone,  which  enabled  me  to  approxi- 
mate the  edges  without  the  slightest  difficulty,  and  union  by  the  first 
intention  occurred.  The  lateral  incisions  should  be  longer  than  the 
opening  in  the  hard  palate,  about  three-fourths  of  an  inch  from  it, 
and  the  mucous  membrane  should  be  detached  the  entire  length  of 
the  incision,  so  as  to  allow  the  edges  to  be  approximated  without 
difficulty. 

Wry  neck  is  another  deformity  which,  although  not  very  common, 
occurs  occasionally,  and  results  from  a  permanent  contraction  or 
shortening  of  the  sterno-cleido-mastoideus  muscle.  All  that  is 
necessary  in  such  cases  is  to  divide  the  muscle  subcutaneously  from 
within  outward.  Take  hold  of  the  muscle  above  the  centre  with  the 
forefinger  and  thumb  of  the  left  hand,  pass  the  tenotomy  knife  with 
the  back  turned  toward  the  vessels,  and  cut  outwards,  being  careful 
not  to  wound  the  skin.  You  cannot  be  too  cautious  when  perform- 
ing operations  upon  the  neck,  particularly  near  the  sternum.  After 
the  muscle  has  been  divided,  the  head  should  be  placed  in  its  proper 
position  and  retained  until  ligamentous  union  takes  place  between 
the  extremities. 

Club-foot  is  the  next  deviation  of  position  to  which  your  atten- 
tion will  be  directed.  It  results  from  a  permanent  contraction  of 
one  or  more  of  the  muscles  of  the  part  implicated.  There  are  four 
distinct  varieties.  In  talipes  varus  the  bottom  or  sole  of  the  foot  is 
turned  inward  and  the  weight  of  the  body  rests  upon  the  outer 
ankle. 


LECTURE    VIII.  —  CLUB-FOOT. 


105 


Fig.  22  represents  this  variety,  which  is  the  most  common,  and  is 
produced  by  a  shortening  of  the  tendo  Achillis,  fascia  plantaris,  and 
sometimes  other  muscles.  I  have  never  in  the  treatment  of  such 


FIG.  22. 


cases  found  it  necessary  to  divide  anything  except  the  tendon  and 
fascia  already  mentioned.  I  am  now  treating  three  cases  of  this 
character  with  an  improved  club-foot  shoe  with  a  very  flattering 
prospect  of  success. 

FIG.  23. 


Fig.  23  represents  a  foot  turned  in  the  opposite  direction,  which 
is  called  talipes  valgus.    The  weight  of  the  body  rests  upon  the  inner 


106 


LECTURES    ON    PRACTICAL    SURGERY. 


ankle.     This  difficulty  is  not  uncommon,  although  it  does  not  occur 
so  frequently  as  the  other  variety. 


FIG.  24. 


Fig.  24  will  give  you  a  correct  idea  of  the  variety  called  talipes 
calcaneus.  The  toes  are  elevated  and  the  heel  only  is  used  in  loco- 
motion. I  saw  a  case  recently  in  which  the  upper  sides  of  both  feet 
were  in  contact  with  the  legs,  in  consequence  of  the  excessive  con- 
traction of  the  muscles. 

Fig.  25  is  a  correct  representation  of  talipes  equinus.  The  lower 
extremities  of  the  metatarsal  bones  are  exceedingly  prominent.  The 
heel  is  drawn  upward  so  much  that  the  extremities  of  the  metatarsal 
bones  are  the  only  part  of  the  sole  of  the  foot  which  is  used  in  loco- 
motion. I  operated  upon  a  gentleman  of  this  city  thirty-eight 
years  old,  and  in  ten  days  he  walked  as  well  as  if  that  difficulty  had 
never  existed. 

The  question  now  arises, — are  these  deformities  curable,  and  if  so 
by  what  means  can  it  be  effected  ? 

When  a  child  is  born  with  either  varus  or  valgus,  a  straight  splint 
well  padded  with  cotton  should  be  applied  upon  the  external  side  of 
the  leg,  extending  from  the  knee  to  the  extremities  of  the  toes,  and 
secured  by  a  bandage  for  the  purpose  of  bringing  the  foot  on  a  line 


LECTURE    VIII.  —  CLUB-FOOT. 


107 


with  the  leg.     When  this  has  been  accomplished  and  the  child  is 
five  or  six  months  old,  in  varus  the  tendo   Achillis  and  plantar 


FIG.  25. 


FIG.  26. 


aponeurosis  should  be  divided  subcutaneously.     The  foot  and  leg 
should  then  be  covered  with  cotton  batting,  and  the  shoe  represented 


FIG.  27. 


by  Fig.  27  applied.      It   is  made  of  perforated  felt,  is  moulded 
on  a  last  the  shape  of  a  healthy  foot,  and  by  its  use,  before  the 


108          LECTURES  ON  PRACTICAL  SURGERY. 

child  is  old  enough  to  walk,  the  foot  will  present  as  natural  an  ap- 
pearance as  it  would  if  that  difficulty  had  not  existed.  Then  the 
leg  portion  can  be  applied  to  an  ordinary  shoe,  or  Tieman's  modifica- 


FIG.  28. 


tion  of  Scarpa's  shoe  substituted.  In  talipes  valgus  the  tendons  of 
the  peroneus  longus  and  brevis  should  be  divided,  and  the  same 
shoe  applied,  after  the  use  of  the  straight  splint  as  already  di- 
rected. 

In  talipes  equinus  the  tendo  Achillis  only  should  be  divided,  and 
when  that  has  been  accomplished,  the  foot  can  be  restored  to  its 
proper  and  natural  position  by  the  use  of  the  same  shoe  in  a  very 
short  time. 

In  talipes  calcaneus  the  tendons  of  the  tibialis  anticus  and  flexor 
communis  digitorum  pedis  should  be  divided,  which  will  enable 
you  to  apply  the  felt  shoe  recommended  for  the  other  varieties,  with 
the  addition  of  a  strap  which  passes  under  the  bottom  of  the  shoe, 
and  is  attached  to  the  posterior  and  upper  portion  of  the  leg-piece, 
for  the  purpose  of  drawing  the  foot  downward  into  its  proper  posi- 
tion. This  shoe  is  all  that  will  be  required  in  the  treatment  of  chil- 
dren, but  in  older  subjects  the  apparatus  represented  by  Fig.  31  is 
preferable.  It  is  made  of  wood,  is  perfectly  simple,  can  be  easily 
adjusted,  and  fulfils  the  indications  better  than  anything  that  has 
been  employed  in  cases  of  talipes  equinus  or  calcaneus. 


LECTURE    VIII.  —  CLUB-FOOT. 


109 


The  tenotomy  knife  should  be  inserted  about  half  an  inch  from 
the  tendon,  and  passed  under  the  skin  until  the  side  of  the  blade  is 
directly  over  it,  when  it  is  relaxed  by  extending  the  foot  so  as  to 
remove  the  danger  of  wounding  the  integument.  The  cutting  edge 


FIG.  29. 


should  then  be  placed  in  contact  with  the  part  to  be  divided.  The 
foot  being  forcibly  flexed,  and  some  pressure  made  upon  the  blade, 
it  will  pass  readily  through  the  tendon,  and  the  tension  will  disap- 


FlG.  30. 


FIG.  31. 


Tieman's  shoe. 


Shoe  for  talipes  equinus  and  simplex. 


pear.  I  have  always  operated  in  this  manner,  and  have  never 
wounded  either  the  anterior  or  posterior  tibial  arteries.  The  oper- 
ation being  completed,  the  wound  should  be  closed  by  the  application 
of  isinglass  plaster  and  a  bandage,  which  should  be  allowed  to  remain 
for  ten  days,  and  then  the  club-foot  shoe  substituted.  When  the 


110  LECTUKES    ON    PRACTICAL    SURGERY. 

deformity  has  been  removed,  and  the  child  is  old  enough  to  walk, 
have  the  leg- piece  attached  to  an  ordinary  laced  boot  without  a  heel, 
and  the  child  will  walk  as  well  as  if  no  difficulty  had  existed. 

Having  always  been  disappointed  by  the  ordinary  club-foot  shoe, 
in  the  treatment  of  young  children,  although  opposed  to  the  increase 
of  surgical  instruments,  I  had  a  simple  apparatus  made  of  felt, 
which  is  cheap,  easily  adjusted,  immovable,  and  consequently  deci- 
dedly superior  to  any  other  instrument  that  has  been  used  in  the 
treatment  of  this  deformity. 

In  every  variety  of  club-foot,  it  is  exceedingly  important  to  protect 
the  integument  by  the  application  of  fine  cotton  batting.  The  foot 
should  be  examined  two  or  three  times  a  week,  in  order  to  ascertain 
whether  the  pressure  be  equably  applied,  so  as  to  prevent  ulceration. 
Besides  the  straps  and  buckles  which  are  intended  to  retain  the  shoe 
in  its  proper  position,  I  frequently  apply  a  bandage,  and  this  is 
especially  necessary  in  talipes  calcaneus.  When  the  skin  is  exces- 
sively irritable,  the  shoe  should  be  removed  at  night,  so  as  to  enable 
the  patient  to  obtain  the  requisite  amount  of  sleep. 

In  flat  or  splay-foot,  as  you  have  already  been  told,  the  external 
side  of  the  foot  is  to  a  greater  or  less  extent  turned  upward,  and  the 
internal  and  middle  portion,  directly  under  the  malleolus  internus, 
is  more  prominent  than  any  other  portion.  This  is  not  always  con- 
genital. When  the  foot  is  not  sufficiently  arched,  the  ligaments  yield 
to  the  weight  of  the  body  so  much,  that  the  foot  is  not  only  flat,  but 
the  centre  becomes  the  most  prominent.  This  difficulty  occurs  most 
frequently  in  delicate  children,  and  in  those  more  advanced,  of  a 
strumous  diathesis,  who  are  compelled  by  their  occupation  to  remain 
long  on  their  feet.  If  it  receive  attention  early,  this  deformity  can 
be  prevented  by  the  application  of  shoes  with  long  broad  heels  and 
stiff  counters,  in  combination  with  tonics,  animal  food,  and  exercise 
suitable  to  the  condition  of  the  patient. 

Adults  with  flat  feet,  who  are  compelled  to  stand  for  eight  or  ten 
hours  in  the  twenty-four,  suffer  great  pain  in  the  afternoon,  which 
is  generally  mistaken  for  rheumatism.  It  is  anterior  to  the  internal 
malleolus,  and  is  located  in  the  ligaments.  To  give  relief,  the  occu- 
pation should,  if  possible,  be  changed,  and  the  heel  of  the  boot  or 
shoe  be  made  at  least  an  inch  longer  than  the  one  ordinarily  worn, 
which  removes  the  weight  of  the  body  from  the  heel,  and  diminishes 
the  tension  of  the  ligaments  by  which  the  tarsal  and  metatarsal  bones 
are  connected. 


LECTURE    VIII.  —  DISEASE    OF    KNEE.  Ill 

This  cut  represents  the  appearance  of  the  lower  extremity,  which 
results  from  an  enlargement  of  the  condyles  of  the  femur.  They 
project  over  the  head  of  the  tibia,  which  rests  upon  the  posterior 
portion  of  the  articulating  surfaces,  and  the  joint  presents  this  extra- 


FIG.  32. 


ordinary  appearance.  In  females  it  frequently  exists  without  being 
detected,  even  by  their  most  intimate  friends,  as  no  perceptible  lame- 
ness exists  in  ordinary  cases.  It  is  always  of  a  strumous  character, 
and  especial  attention  should  be  paid  to  the  general  health. 

The  feet  are  liable  to  a  peculiar  disease  called  podelcoma  or  ground 
itch.  I  have  known  it  often  to  result  from  the  feet  being  allowed 
to  remain  in  mud  and  water  for  several  hours  in  succession,  which 
frequently  is  the  case  with  boys  in  the  Southern  States  who  are  fond 
of  fishing,  and  indulge  in  that  amusement  barefooted.  It  appears 
on  the  soles  of  the  feet  as  well  as  between  the  toes.  It  is  accom- 
panied with  excessive  itching,  and  sometimes  with  great  pain  and 
ulceration.  The  best  remedy  is  citrine  ointment,  combined  with  an 
equal  quantity  of  lard,  which  may  be  applied  morning  and  evening 
until  the  disease  is  controlled,  and  then  simple  cerate  should  be  sub- 
stituted. 

Pododynia,  or  pain  in  the  soles  of  the  feet,  is  very  common,  and 
results  from  remaining  too  long  upon  them.  Tailors,  clerks,  and 
others,  compelled  to  stand  ten  or  twelve  hours  a  day,  are  very  liable 
to  this  troublesome  difficulty.  I  have  suffered  from  it  occasionally 
from  the  same  cause,  and  the  best  remedy  which  I  have  employed 
is  to  shower  the  feet  with  water  as  hot  as  it  can  be  borne,  at  night, 
and  by  morning  the  pain  will  have  disappeared,  but  is  always  liable 
to  occur  from  a  repetition  of  the  cause.  It  is  more  inconvenient 
than  serious,  and  is  only  mentioned  because  we  are  frequently  con- 
sulted in  such  cases,  and  are  expected  to  prescribe  remedies  that  will 
afford  relief. 


112  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE    IX. 

GENTLEMEN  :  We  have  not  yet  finished  congenital  malforma- 
tions. Those  omitted  are  occlusion  of  the  rectum,  and  nsevus.  The 
lower  extremity  of  the  rectum  may  be  closed  simply  by  the  mucous 
membrane.  In  such  cases  the  bowels  are  constipated ;  the  child  be- 
comes restless ;  vomits  frequently ;  the  abdomen  is  distended,  and 
jaundice  frequently  makes  its  appearance  in  three  or  four  days  after 
birth,  provided  the  obstruction  is  not  removed.  When  such  symp- 
toms appear,  always  examine  the  anus,  and  if  you  find  it  closed,  but 
prominent  and  elastic,  the  protruding  part  should  be  divided  either 
with  a  lancet  or  bistoury.  The  contents  of  the  bowels  will  then 
escape,  and  no  more  inconvenience  will  be  experienced. 

The  rectum  may  be  deficient  for  an  inch  or  more,  and  all  the 
symptoms  enumerated  will  exist,  except  the  prominence  resulting 
from  the  distended  rectum.  A  case  of  this  character  occurred  a  few 
years  ago,  in  which  a  transverse  incision  was  made  an  inch  in  depth 
before  the  extremity  of  the  rectum  could  be  discovered.  It  was 
then  opened  freely  with  a  bistoury,  and  kept  from  closing  by  the  use 
of  the  largest  gum-elastic  male  bougie,  which  was  introduced  every 
alternate  day,  and  allowed  to  remain  fifteen  or  twenty  minutes.  In 
the  third  variety  the  rectum  opens  either  into  the  bladder  or  vagina ; 
either  case  is  very  serious,  and  difficult  to  treat  successfully.  I 
attended  a  case  in  this  city  in  which  the  rectum  terminated  in  the 
vagina  about  half  an  inch  from  the  vulva.  An  opening  was  made 
through  the  perineum  into  the  extremity  of  the  rectum,  and  when 
established,  that  which  existed  in  the  vagina  was  closed  by  the  in- 
terrupted silver  suture  by  a  single  operation.  When  the  rectum 
terminates  in  the  bladder  the  case  is  beyond  the  control  of  the  sur- 
geon. 

Naevus  is  a  congenital  difficulty  of  considerable  importance,  but 
not  so  dangerous  as  surgeons  formerly  supposed.  It  is  a  disease  of 
the  bloodvessels,  and  generally  those  of  the  skin  only  are  implicated. 
It  may  result  either  from  an  enlargement  of  veins  or  capillaries,  but 
when  the  arterial  circulation  is  increased,  it  is  called  aneurism  by 


LECTURE    IX.  —  NJEVUS,  113 

anastomosis.  You  will  often  meet  persons  with  some  portion  of  the 
face  disfigured  by  this  enlargement  of  the  bloodvessels.  When  the 
veins  only  are  implicated  the  part  does  not  present  a  bright-red  ap- 
pearance, and  no  pulsation  can  be  detected.  When  the  arteries  are 
both  enlarged  and  increased  in  number,  the  color  is  not  only  more 
bright,  but  there  also  exists  a  distinct  pulsation  which  corresponds 
with  that  of  the  heart.  When  a  nsevus  of  this  character  is  removed 
and  examined,  it  will  be  found  to  be  composed  entirely  of  blood- 
vessels united  by  cellular  tissue.  It  is  called  nsevus  or  mother's 
mark,  because  it  is  generally  believed  that  it  results  from  some 
mental  impression  experienced  by  the  mother  during  gestation. 
Some  years  since  I  published  in  the  Pacific  Medical  Journal  some 
singular  cases  of  this  character,  which  could  not  be  otherwise  ex- 
plained. When  the  vessels  become  greatly  enlarged,  ulceration  fre- 
quently takes  place,  and  then  the  hemorrhage  is  often  profuse. 
W^hen  they  are  located  where  pressure  cannot  be  made,  it  becomes 
necessary  to  ligate  the  vessels  which  furnish  the  blood,  A  few  days 
since  I  saw  a  child  six  weeks  old  with  an  immense  nsevus  above  the 
left  eye,  that  was  bleeding  profusely.  The  haemorrhage  was  arrested 
by  the  application  of  Monsel's  salt,  and  the  parents  advised  to  have 
the  temporal  artery  ligated  so  soon  as  the  child  recovered  from  the 
loss  of  blood'  which  it  had  sustained.  When  a  nsevus  is  located 
where  compression  can  be  made,  then  it  should  be  removed  either 
with  the  knife  or  scissors,  no  matter  how  large  it  may  be. 

I  have  never  experienced  the  least  difficulty  in  arresting  the  haem- 
orrhage after  such  an  operation.  A  fold  of  wet  lint  larger  than 
the  nsevus  should  be  covered  with  Monsel's  salt,  and  held  by  an 
assistant  so  that  it  can  be  applied  in  an  instant  after  the  nsevus  is  re- 
moved, which  if  it  be  small  can  be  done  more  conveniently  with  scis- 
sors than  with  either  a  scalpel  or  bistoury.  The  nsevus  should  be 
raised  with  a  tenaculum,  and  excised  with  curved  scissors;  Monsel's 
salt  should  then  be  firmly  applied,  and  retained  four  or  five  minutes, 
and  then  removed.  Should  any  hsemorrhage  exist,  the  salt  should 
be  reapplied  in  the  same  manner,  which  never  fails  to  close  every 
bleeding  vessel. 

I  was  taught  that  it  was  dangerous  to  interfere  with  nsevi  at  all, 
and  particularly  with  cutting  instruments;  but  so  soon  as  I  was  con- 
vinced of  the  extraordinary  hsemostatic  properties  of  Monsel's  salt, 
I  was  satisfied  that  the  hsemorrhage  could  by  its  use  be  easily  con- 

8 


114  LECTURES    ON    PRACTICAL    SURGERY. 

trolled,  and  have  never  hesitated  to  excise  them  except  when  lo- 
cated near  the  eye,  or  upon  the  neck,  and  then  the  ligature  should 
be  preferred.  Recently  a  child  six  months  old  was  brought  to  the 
city  from  Siskiyou  County,  with  an  enormous  tumor  of  this  charac- 
ter upon  the  back  of  the  neck.  It  being  impossible  to  make  perma- 
nent compression  in  that  locality,  an  incision  half  an  inch  in  length 
was  made  through  the  skin  on  each  side  of  the  base  of  the  tumor;  a 
large  curved  needle  armed  with  a  strong  double  ligature  was  passed 
from  side  to  side  under  the  nevus,  and  then  subcutaneously  so  that 
each  ligature  should  embrace  and  destroy  the  circulation  of  one- 
half  of  the  tumor.  The  operation  was  so  extensive  for  a  child  of 
that  age,  that  a  violent  fever  followed  accompanied  with  convulsions. 
Eight  ounces  of  blood  were  taken  from  the  arm ;  a  depressant  mix- 
ture was  given,  and  cold  applied  to  the  head ;  the  symptoms  were 
speedily  overcome;  on  the  eighth  day  the  integument  was  detached 
without  hemorrhage,  and  on  the  twelfth  the  ligatures  were  re- 
moved, leaving  a  healthy  granulating  surface,  which  cicatrized  so 
rapidly  that  in  three  weeks  the  child  returned  home,  and  it  is  now  in 
good  health.  Four  years  ago  I  removed  from  the  middle  and  inner 
portion  of  the  thigh  of  a  child  two  years  old  a  nsevus,  which  was 
three  inches  long  and  two  in  W7idth.  The  tumor  was  raised  suffi- 
ciently to  allow  the  sharp-pointed  blade  of  a  pair  of  strong  scissors 
to  be  passed  longitudinally  under  it,  and  by  closing  the  blades  half 
the  tumor  was  removed,  and  the  remainder  so  soon  as  the  position 
of  the  scissors  could  be  changed.  Lint  wet  and  covered  with  Mon- 
sel's  salt  was  applied  instantaneously,  and  not  a  tablespoonful  of 
blood  was  lost.  The  application  should  be  secured  by  a  bandage, 
and  allowed  to  remain  until  it  is  detached  by  suppuration.  Secon- 
dary haemorrhage  has  not  occurred  in  a  single  case,  so  that  you 
need  never  hesitate  to  pursue  this  course  when  sufficient  pressure 
can  be  made  to  confine  the  lint  firmly  upon  the  wound.  The  salt 
should  be  applied  as  speedily  as  possible,  so  that  blood  may  not  in- 
tervene between  it  and  the  extremities  of  the  divided  vessels. 

The  blood  coagulates  firmly  so  soon  as  it  comes  in  contact  with 
MonsePs  salt;  it  enlarges  and  consequently  occludes  the  vessels  with 
as  much  certainty  as  a  ligature.  Drs.  Carman  and  Trask  of  this 
city  witnessed  the  first  operation  of  this  character  that  was  ever  per- 
formed, and  to  satisfy  them  of  the  hemostatic  properties  of  MonsePs 


LECTURE    IX.  —  TDMORS.  115 

salt,  in  two  minutes  the  lint  was  removed  and  not  a  drop  of  blood 
followed. 

Other  remedies  have  been  recommended  in  such  cases.  Some  re- 
sort to  vaccination  if  the  tumor  be  small,  others  advise  the  use  of 
hot  needles ;  but  they  both  fail  when  the  tumor  is  either  large  or  the 
discoloration  extensive.  They  should  never  be  performed  when  an 
operation  which  is  more  expeditious,  less  painful,  much  more  safe, 
and  produces  less  deformity,  can  be  substituted. 

I  have  said  all  that  I  consider  it  necessary  to  say  about  congenital 
malformations,  and  will  finish  this  lecture  with  some  remarks  on 
diseased  nutrition.  The  action  of  the  capillary  vessels  by  which 
the  texture  of  a  part  is  either  altered  or  increased  in  size  is  called 
diseased  nutrition,  and  all  the  morbid  growths  thus  produced  are 
called  tumors.  The  word  tumor  is  applicable  to  every  disease  in 
which  the  part  is  increased  in  magnitude.  When  an  effusion  of 
serum  takes  place  into  the  tunica  vaginalis,  a  tumor  is  formed 
which  is  called  a  hydrocele. 

The  natural  tissues  of  a  part  may  be  simply  enlarged,  as  the 
periosteum  in  exostosis.  In  such  cases  there  is  an  increase  of  the 
tissues,  and  consequently  the  bone  becomes  enlarged,  but  still  the 
texture  is  not  changed. 

They  may  be  converted  into  textures  foreign  to  the  healthy  con- 
dition of  the  body,  as  in  cancer.  New  formations  may  also  be  devel- 
oped, as  in  fibrous  tumors.  In  these  there  is  a  formation  different 
from  the  original  structure  of  the  part;  still  it  may  not  be  prejudicial 
to  or  incompatible  with  a  healthy  condition  of  the  body,  or  in  other 
words  it  is  neither  dangerous  nor  necessarily  fatal  if  allowed  to  re- 
main, although  an  unnatural  development.  Such  growths  may  occur 
in  any  portion  of  the  body,  but  are  more  frequently  located  in  the 
glands  and  cellular  tissue. 

They  do  not  increase  with  any  degree  of  uniformity.  When  the 
part  is  kept  at  rest  and  attention  is  paid  to  the  general  health,  they 
usually  enlarge  very  slowly,  but  if  violent  exercise  be  taken  or  ir- 
ritants be  applied,  or  should  inflammation  result  from  any  other 
cause,  then  the  tumor  will  increase  with  great  rapidity. 

They  may  be  removed  by  absorption,  mortification,  or  excision. 
The  method  most  suitable  for  each  variety  will  be  specified  when 
it  is  under  consideration. 

Abernethy  divided  tumors  into  sarcomatous  and  encysted,  and 


116  LECTURES    ON    PRACTICAL    SURGERY. 

they  may  be  subdivided  into  the  simple  or  benign,  semi-malignant, 
and  malignant.  There  are  tumors  which  never,  no  matter  what  mag- 
nitude they  acquire  or  how  long  they  remain,  become  malignant. 

1.  The  simplest  tumor  is  called  vascular  sarcoma.     The  enlarge- 
ment is  produced  by  the  distension  of  the  bloodvessels,  and  the  ef- 
fusion of  serum  or  plastic  lymph  into  the  cellular  tissue.    The  parts 
most  liable  to  this  change  of  structure  are  the  testicles,  thyroid 
gland,  and  scrotum.     Your  attention  has  been  directed  in  the  sur- 
gical ward  to  a  case  of  enlargement  of  the  thyroid  gland,  which  is  of 
that  character.     It  is  not  painful,  although  it  has  enlarged  rapidly, 
both  by  the  increase  of  vascularity  and  by  the  effusion  and  organiza- 
tion of  plastic  lymph. 

2.  Warts  and  polypi  also  belong  to  this  class ;  with  the  appear- 
ance of  the  former  you  are  all  familiar.     They  are  excrescences  de- 
veloped upon  the  skin,  and  when  exposed,  are  usually  firm  and  may 
present  either  a  rough  or  smooth  surface,  but  when  they  occur  upon 
the  prepuce,  the  perineum  of  the  female,  or  upon  any  other  portion 
of  the  body  which  is  kept  moist  by  the  natural  secretions  of  the 
part,  they  are  soft  and  flat,  and  are  called  condylomata  or  mucous 
tubercles. 

The  mucous  polypus  is  of  the  same  character,  although  it  pre- 
sents a  different  appearance.  It  is  much  longer  and  larger,  being  a 
pendulous  mass  of  a  reddish  color,  soft,  and  of  a  delicate  texture. 
It  may  be  attached  to  or  grow  from  any  mucous  membrane,  and 
is  composed  of  the  natural  elements  of  this  tissue.  It  is,  however, 
found  most  frequently  in  the  nose  and  the  mouth  of  the  uterus. 

Treatment. — When  warts  are  located  either  upon  the  hands  or  feet, 
or  on  other  parts  which  are  not  very  sensitive,  acetic  acid  should  be 
applied  morning  and  evening  until  they  disappear.  When  located 
upon  the  eyelids  a  ligature  should  always  be  applied.  Mucous  tuber- 
cles, when  situated  upon  the  glans  penis  or  prepuce,  if  neglected 
frequently  become  not  only  excessively  large  but  also  firm  and  very 
irregular.  Should  they  be  removed  by  a  cutting  instrument,  even  if 
escharotics  be  subsequently  applied,  they  will  invariably  return. 
You  may  burn  them  off  with  sulphate  of  copper,  nitrate  of  silver, 
or  nitric  acid,  and  still  they  reappear ;  but  if  you  apply  a  ligature 
sufficiently  tight  to  destroy  their  vitality,  they  will  seldom  return. 
Until  by  experience  I  ascertained  this  fact,  there  was  no  simple  dis- 


LECTURE    IX.  —  TUMORS.  117 

ease  that  annoyed  me  so  much.  They  may  result  from  want  of 
cleanliness,  from  gonorrhoea,  and  probably  from  syphilis,  although 
I  still  entertain  some  doubts  as  to  the  possibility.  Without  regard 
to  the  cause,  the  local  treatment  should  be  the  same.  When  they 
are  large  and  numerous  the  ligature  should  include  as  many  as  can 
be  effectually  strangulated,  and  the  operation  should  be  repeated 
until  they  are  all  removed. 

It  is  unnecessary  to  ligate  a  uterine  mucous  polypus ;  they  are  so 
delicate  that  they  will  seldom  bear  a  ligature,  and  when  removed 
with  dressing  forceps  they  seldom  return.  When  located  in  the  nose 
it  is  frequently  impossible  to  find  the  pedicle,  and  if  found  it  is  ex- 
ceedingly difficult  to  apply  a  ligature,  consequently  we  are  frequently 
compelled  to  resort  to  the  very  unsatisfactory  operation  of  removing 
them  with  the  forceps.  Lisfranc  advised  his  class,  in  consequence  of 
their  great  liability  to  return,  to  do  as  much  violence  to  the  mucous 
membrane  as  possible  with  the  forceps,  so  as  to  prevent  that  occur- 
rence. Sometimes  they  do  not  reappear  after  being  removed,  occa- 
sionally they  do  return  at  long  intervals,  but  generally  they  recur  so 
frequently  as  to  prove  a  source  of  great  annoyance,  although  they 
never  become  malignant. 

3.  The  third  variety  of  simple  tumor  is  well  represented  by  the 
specimen  exhibited.  This  is  an  adipose  or  fatty  tumor,  and  was 
removed  three  weeks  ago  from  the  back  of  a  young  woman  of  this 
city.  It  resembles  perfectly  pure  white  fat.  They  are,  however, 
sometimes  yellowish  in  appearance.  They  are  never  painful;  are 
not  intimately  connected  with  the  surrounding  parts,  and  contain 
but  few  bloodvessels. 

They  are  generally  rendered  irregular  in  shape  by  processes  being 
thrown  out  from  the  body  of  the  tumor.  The  largest  of  this  variety 
which  I  have  ever  seen  was  removed  from  the  neck  of  an  old  lady, 
who  lived  at  28  Jackson  Street.  It  had  been  previously  removed  by 
Drs.  Mott  and  Parker,  and  returned,  and  when  she  left  New  York 
it  was  about  as  large  as  a  man's  fist ;  after  she  reached  San  Francisco 
it  increased  with  great  rapidity,  and  finally  she  was  forced  by  its 
immense  magnitude  to  submit  to  a  third  operation.  It  extended 
from  the  ear  to  the  shoulder ;  the  skin  was  ulcerated,  which  with  the 
excessive  weight  induced  her  to  adopt  this  course,  although  she  had 
but  little  hope  of  permanent  relief.  The  operation  was  performed 
six  years  ago,  and  every  portion  was  carefully  removed  to  prevent  a 


118  LECTURES    ON    PRACTICAL    SURGERY. 

recurrence.  The  tumor  weighed  seven  pounds ;  she  recovered 
rapidly,  is  now  well,  and  no  deformity  resulted  from  its  removal. 

Adipose  tumors  are  very  variable  in  size,  and  if  upon  an  exposed 
portion  of  the  body  should  be  excised  so  soon  as  they  are  discovered, 
in  order  to  prevent  the  deformity  which  must  result  from  an  exten- 
sive cicatrix.  In  operations  upon  all  simple  or  semi-malignant 
tumors,  you  should  divide  everything  which  intervenes  between  the 
skin  and  tumor,  and  then  it  can  be  more  easily  removed,  and  the 
haemorrhage  inseparable  from  the  division  of  the  surrounding  vessels 
avoided.  When  the  sac  is  opened,  but  few  adhesions  will  be  found, 
and  the  tumor  seldom  returns.  A  small  portion  of  wet  lint  should 
be  placed  in  the  most  dependent  portion,  in  order  to  drain  it  effectu- 
ally, and  the  remainder  closed  by  the  interrupted  silver  suture. 
The  warm -water  dressing  should  always  be  preferred,  and  the 
patient  should  not  be  allowed  to  attend  to  his  ordinary  business. 
Always  before  closing  the  wound  be  sure  that  the  tumor  has  been 
entirely  removed,  for  another  of  the  same  magnitude  will  be  speedily 
developed  from  the  smallest  nucleus. 

4.  Cystic  Sarcoma  or  Encysted  Tumors. — These  are  met  with  most 
frequently  in  the  ovaries,  but  may  occur  in  the  testicles  and  mammae. 
They  may  be  unilocular  or  those  of  one  cyst,  or  multilocular,  which 
are  composed  of  numerous  cysts.  They  usually  vary  as  much  in 
size  as  they  do  in  the  character  of  their  contents.  One  cyst  may 
contain  a  fluid  about  the  color  and  consistence  of  honey,  another 
serum,  a  third  bone,  and  a  fourth  balls  the  size  of  a  large  marble  re- 
sembling mutton  tallow,  enveloped  with  hair  from  twelve  to  eighteen 
inches  in  length.  I  removed  one  some  years  since  from  a  negro 
woman,  which  presented  the  peculiarities  specified.  The  hair  was 
straight,  light-colored,  and  at  least  eighteen  inches  long,  and  the 
hair  upon  her  head  was  black,  short,  and  curly,  there  being  not  the 
slightest  resemblance  between  them.  If  the  contents  had  not  been 
separated  by  distinct  partitions,  it  might  be  supposed  to  have  re- 
sulted from  an  extra-uterine  pregnancy.  They  are  inconvenient  by 
their  magnitude,  and  dangerous  by  their  position.  They  as  well  as 
all  other  tumors  vary  in  size.  This  jar  contains  what  remains  of  a 
tumor  of  that  character.  It  weighed  about  seventy-five  pounds.  It 
was  unilocular;  fifty-seven  pints  of  serum  was  removed,  which  with 
the  solid  portion  exhibited  must  have  weighed  that  much. 

When  located  in  the  mammae  or  testicles,  they  do  not  require 


LECTURE    IX.  —  TUMORS.  119 

special  treatment,  and  should  be  removed  either  with  or  without 
the  organ,  as  may  be  necessary.  When  they  occur  in  the  ovaries 
they  are  always  dangerous,  being  beyond  the  control  of  medical 
treatment.  An  operation  is  required  for  their  removal,  which  is  ex- 
tremely hazardous,  and  therefore  should  never  be  performed  unless 
there  exists  the  most  urgent  necessity. 

5.  Encysted  Tumors  or  Wens. — These  occur  very  frequently,  and 
consist  of  a  cyst  and  its  contents,  which  may  be  either  fluid,  semi- 
fluid, or  solid. 

The  first  variety  is  called  melicerous,  from  its  resemblance  to 
honey ;  the  second,  atheromatous,  or  like  putty ;  the  third,  steatoma- 
tous,  like  lard. 

In  size  they  usually  vary  from  the  size  of  a  pea  to  that  of  a  wal- 
nut, although  they  sometimes  become  much  larger.  The  cyst  is 
generally  firm,  and  contains  the  substances  already  specified.  They 
are  usually  located  immediately  under  the  skin  or  mucous  membrane, 
and  are  found  most  frequently  under  the  scalp,  although  they  may 
occur  upon  any  portion  of  the  body.  For  a  time  they  are  not  con- 
nected intimately  with  the  skin,  are  usually  oblong,  and  resemble  an 
egg  in  shape.  They  are  always  movable,  except  when  the  sac  be- 
comes inflamed  either  by  violence  or  excessive  distension  ;  then  they 
become  fixed,  and  their  removal  is  more  difficult.  Sometimes  the 
sac  and  integument  both  ulcerate,  the  contents  escape,  and  an  ulcer 
remains,  which  can  only  be  healed  by  removing  the  remainder  of 
the  cyst.  The  ulcers  produced  in  this  manner  are  supposed  to  give 
origin  to  the  horny  excrescences  met  with  and  described.  A  very 
remarkable  production  of  that  character  is  represented  by  a  wood- 
cut in  Syme's  work  on  Surgery.  It  was  more  than  six  inches  in 
length,  and  nearly  an  inch  in  diameter.  As  these  tumors  are  simple, 
and  never  return  when  entirely  removed,  excision  should  always  be 
recommended  before  they  become  sufficiently  large  to  give  much 
inconvenience. 

The  most  expeditious  method  of  operating  is  to  make  a  free  inci- 
sion through  the  skin  and  sac,  and  when  the  contents  are  removed, 
to  take  hold  of  the  edge  with  strong  artery  or  dressing  forceps ;  if 
located  on  the  head,  the  use  of  the  knife  is  entirely  unnecessary. 
When  situated  elsewhere,  and  more  or  less  intimately  connected 
with  the  surrounding  parts,  the  sac  should  be  opened  and  dissected 
out,  because  by  pursuing  that  course  the  external  wound  required  is 


120  LECTURES    ON    PRACTICAL    SURGERY. 

much  less  extensive,  and  should  never  be  healed  by  the  first  inten- 
tion. When  on  the  scalp  and  covered  by  hair,  they  need  no  dressing, 
but  when  on  the  face,  neck,  or  forehead,  they  should  be  partially 
closed  by  the  interrupted  silver  suture,  with  a  small  portion  of  wet 
lint  placed  in  the  most  dependent  portion  of  the  wound,  and  the 
water-dressing  applied. 

When  a  wen  is  located  upon  the  centre  of  the  neck,  between  the 
larynx  and  chin,  make  an  incision  through  the  skin  where  elevated, 
which  will  expose  the  tumor.  Should  adhesions  exist,  destroy  them 
with  the  finger  or  handle  of  the  scalpel,  and  apply  a  ligature  upon 
the  base,  otherwise  haemorrhage  may  follow,  as  was  the  case  many 
years  since  in  one  of  my  operations.  The  tumor  was  removed  late  in 
the  afternoon,  and  a  branch  of  the  inferior  thyroid  of  the  right  side 
was  divided  ;  a  ligature  could  not  be  applied  at  night,  consequently 
the  haemorrhage  could  only  be  controlled  by  the  application  of  spring 
acting  forceps,  which  were  allowed  to  remain  during  the  night,  and 
removed  the  following  morning  by  torsion,  without  being  followed 
by  a  return  of  the  haemorrhage. 

Since  that  occurrence,  in  all  operations  upon  deepseated  tumors 
upon  the  neck,  in  order  to  prevent  haemorrhage,  both  arterial  and 
venous,  from  regurgitation,  I  always  apply  a  strong  ligature  between 
the  tumor  and  its  deep  attachment,  and  have  not  since  been  troubled 
with  haemorrhage.  The  ligature  also  serves  to  drain  the  wound, 
which  is  very  important  in  that  locality. 

6.  The  tumors  described  as  neuromatous  and  subcutaneous  tuber- 
cle are  so  nearly  alike  in  location,  appearance,  and  symptoms, 
that  I  have  never  been  able  either  before  or  after  their  removal 
to  discover  any  difference.  They  sometimes  acquire  considerable 
magnitude,  are  always  exceedingly  painful,  and  interfere  with  the 
function  of  the  nerve  involved.  They  differ  from  every  other  variety 
of  simple  tumor  in  that  respect,  but  more  particularly  in  the  exces- 
sive sensibility  of  the  surface  which  always  exists.  A  few  weeks 
since  I  removed  a  tumor  of  this  character  from  the  ankle  of  a  lady 
of  this  city,  which  although  not  larger  than  a  buckshot,  had  been 
for  more  than  a  year  a  source  of  constant  torment.  She  could  not 
bear  the  bed-clothes  to  touch  that  side- of  the  leg,  consequently  her 
sleep  was  always  more  or  less  disturbed.  Twenty  years  ago  I  re- 
moved a  tumor  of  this  character  as  large  as  a  chestnut  from  the  left 
side  of  the  chest  of  ap  old  gentleman,  who  had  not  been  free  from 


LECTURE    IX.  —  HYDATIDS.  121 

pain  for  many  years.  Besides  being  painful,  it  was  so  excessively 
sensitive,  that  he  was  compelled  to  protect  it  from  his  clothes  by 
wearing  a  ring  made  of  cloth  and  cotton,  about  three  inches  in  diam- 
eter and  an  inch  thick,  which  was  kept  in  its  position  by  a  shoulder- 
strap  and  bandage.  In  such  cases  the  patient  should  be  rendered 
insensible  by  an  anaesthetic,  the  tumor  removed  as  speedily  as  possi- 
ble, and  the  wound  treated  as  if  it  had  resulted  from  any  other 
cause. 

7.  Hydatid. — A  cyst  which  incloses  a  vesicular  worm  is  called 
a  hydatid.  It  is  a  parasite,  and  each  worm  or  echinococcus  consists 
of  a  distinct  head  and  body,  and  is  furnished  with  teeth  that  can  be 
seen  distinctly  with  a  microscope.  When  they  occur  in  the  liver 
they  may  prove  fatal;  occasionally,  however,  suppuration  takes  place, 
and  if  it  be  allowed  to  escape  through  a  large  external  opening,  the 
hydatids  may  accompany  it  and  the  patient  recover.  The  specimen 
exhibited  is  the  most  perfect  I  have  ever  seen.  It  existed  in  the 
uterus,  was  accompanied  with  all  the  symptoms  of,  and  was  mistaken 
for,  Bright's  disease  of  the  kidneys.  The  urine  was  highly  albumi- 
nous, the  sight  was  impaired,  all  the  cavities  were  partially  filled 
with  serum,  and  she  was  excessively  feeble.  Her  case  being  con- 
sidered hopeless  by  her  physicians,  I  was  requested  to  see  her,  and 
upon  inquiry  I  found  that  she  had  not  menstruated  for  four  months, 
and  there  being  a  decided  enlargement  and  induration  in  the  hypo- 
gastric  region,  a  sound  was  passed  into  the  uterus  with  the  view  of 
producing  expulsive  pains  sufficient  to  remove  the  contents,  and  the 
following  evening  the  specimen  which  I  present  was  extruded.  In 
a  few  days  the  albumen  disappeared  from  the  urine,  the  serum  effused 
was  speedily  absorbed  and  eliminated,  and  her  health  was  soon  re- 
stored. In  twelve  months  after  she  was  relieved  of  this  difficulty 
I  delivered  her  of  a  healthy  child,  which  is  still  in  good  health. 

According  to  this  classification  there  are  seven  simple  or  benign 
tumors,  which  whan  entirely  removed  do  not  return,  and  become 
injurious  and  troublesome  only  by  their  size  and  location. 

The  next  lecture  will  be  devoted  to  serai-malignant  and  malignant 
tumors. 


122  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   X. 

SEMI-MALIGNANT  TUMORS  include  the  fibrous  and  epithelial.  The 
former  are  divided  by  Syrae  into  the  tubercular,  pancreatic,  and 
fibro-cartilaginous.  More  recent  pathologists  have  described  other 
varieties,  which  are  arranged  under  the  following  heads :  1st.  Fibrous. 
2d.  Malignant  fibrous.  3d.  Recurring  fibrous.  4th.  Fibro-plastic 
or  enchondromatous.  5th.  Keloid. 

The  surface  of  fibrous  tumors  is  generally  irregular,  although  the 
specimen  I  now  exhibit  is  almost  perfectly  smooth.  They  also  vary 
in  density  from  the  firmness  of  cartilage  to  the  consistence  of  the 
pancreas.  The  size,  as  in  all  other  tumors,  is  exceedingly  variable. 
They  generally  present  a  gray  or  yellowish  appearance ;  when  di- 
vided with  the  knife  they  impart  a  gritty  sensation  to  the  hand.  A 
section  presents  a  whitish  hue,  and  is  composed  of  ligamentous  tissue 
and  nucleated  fibres.  They  are  surrounded  by  what  appears  to  be  a 
capsule,  which  is  firm  and  strong^  and  composed  of  condensed  cel- 
lular tissue. 

When  the  material  of  the  tumor  is  deposited,  the  cellular  tissue 
envelops  it  closely,  and  when  thickened  by  pressure  is  called  a  cap- 
sule. These  tumors  may  remain  almost  stationary,  or  increase  very 
slowly  for  many  years;  if  small  they  are  only  inconvenient,  but 
when  large  they  may  prove  fatal  by  deranging  the  functions  of  the 
important  organs  in  the  vicinity,  without  the  tumor  having  under- 
gone any  decided  structural  change.  After  a  greater  or  less  period, 
however,  it  usually  happens  that  disintegration  commences  inter- 
nally, the  structure  becomes  changed,  and  the  skin  finally  inflames, 
ulcerates,  and  the  fluid  contents  escape,  leaving  a  rough,  fungous, 
bleeding  ulcer  of  a  character  so  malignant  that  all  the  constitutional 
symptoms  observed  in  cancer  speedily  become  apparent.  Occasion- 
ally these  tumors  soften  in  the  centre;  the  solid  structure  disappears, 
leaving  a  cyst,  filled  with  a  fluid  which  is  not  uniform  in  color,  and 
which  may  be  mistaken  for  an  ordinary  cystic  tumor. 

The  malignant  fibrous  tumor  resembles  in  every  respect  the  one  I 
have  endeavored  to  describe,  and  we  become  convinced  of  a  difference 
only  by  the  decided  tendency  to  return. 


LECTURE    X.  —  ENCHONDROMA.  123 

The  fibro-plastic  tumor  was  first  described  by  Lebert  in  his  splen- 
did work  on  pathology.  He  thinks  it  occupies  a  position  interme- 
diate between  the  fibrous  and  fibro-cellular.  They  present  the 
fibrous  structure  with  fibro-plastic  cells  and  elongated  nuclei ;  when 
divided  they  present  a  shining  moist  appearance,  and  the  surface  is 
discolored  by  spots  that  may  be  red,  pinkish-brown,  or  livid.  They 
resemble  flesh,  are  riot  tenacious,  occur  most  frequently  in  young 
people,  and  are  generally  located  either  in  the  bones,  on  the  neck, 
face,  or  mammae.  When  removed  they  occasionally  return. 

Recurring  Fibroid  Growths. — We  are  indebted  to  Paget  for  a  cor- 
rect description  of  these.  In  appearance  they  resemble  the  common 
fibrous  tumors,  but  their  minute  structure  is  of  a  fibro-plastic  charac- 
ter; the  microscope  reveals  the  existence  of  very  narrow,  elongated, 
caudate,  and  oat-shaped  nucleated  cells,  many  of  which  have  long  and 
subdivided  terminal  processes.  This  variety  is  exceedingly  liable 
to  recur,  and  the  malignancy  appears  to  increase  after  each  excision, 
although  the  third  or  fourth  operation  has  occasionally  proved  suc- 
cessful. 

Enchondroma. — This  is  not  uncommon,  and  presents  two  varieties. 
The  first  and  most  simple  never  becomes  large.;  it  increases  very 
slowly  and  is  never  painful.  It  presents  a  smooth,  firm,  round,  and 
flattened  or  ovoid  appearance.  It  occurs  usually  in  the  small  and 
short  bones,  as  the  phalanges  of  the  fingers. 

In  the  other  variety  the  tumor  increases  with  great  rapidity,  and 
often  in  a  few  months  becomes  enormously  large.  They  sometimes 
ossify  at  one  point,  whilst  they  become  less  consistent  at  another, 
and  ultimately  the  skin  inflames  and  ulcerates,  as  in  the  other  va- 
rieties, through  which  a  fluid  resembling  jelly  escapes  in  greater  or 
less  abundance,  according  to  the  extent  of  the  cavity.  The  follow- 
ing are  the  microscopic  appearances  given  by  Erichsen  in  his  valu- 
able work  on  Surgery :  "  The  plate  shows  a  distinct  matrix,  in  places 
dimly  granular,  in  others  slightly  fibrous,  imbedded  in  which  are 
cells  and  nuclei  of  various  forms  and  sizes,  some  round  or  irregu- 
larly oval,  from  ^J^th  to  gj^th  of  an  inch  in  diameter;  many  are 
branched  or  caudate.  Some  of  the  spheroidal  cells  are  granular, 
others  have  nuclei  of  irregular  outline,  and  interspersed  amongst 
them  are  a  few  oil-globules.  The  general  appearance  is  that  of 
foetal  cartilage,  from  which  it  can  with  difficulty  be  distinguished." 
Fibrous  tumors  cannot  easily  be  mistaken  for  those  of  a  different 


124  LECTURES    ON    PRACTICAL    SURGERY. 

character.  They  are  more  firm  and  less  movable  than  the  encysted, 
arid  differ  in  shape,  locality,  and  consistence  from  the  fatty,  are  less 
hard  and  painful  than  the  scirrhous,  are  not  so  rapidly  developed, 
and  are  less  elastic  than  the  encephaloid,  colloid,  and  melanotic 
tumors.  The  most  common  location  is  in  the  vicinity  of  the  paro- 
tid gland,  although  they  frequently  occur  in  the  antrum  Highmori- 
anum,  or  mamma3,  as  well  as  upon  some  other  portions  of  the  body. 
I  have  removed  three  large  fibrous  tumors  that  were  located  between 
the  abdominal  muscles  and  peritoneum.  One  was  situated  above 
the  umbilicus  on  the  left  side.  The  peritoneum  was  removed  with 
the  tumor,  in  consequence  of  the  union  being  so  intimate  that  they 
could  not  be  separated.  In  the  other  cases  the  tumor  was  located 
upon  the  right  and  lower  portion  of  the  abdomen ;  each  weighed 
about  four  pounds  ;  they  were  removed  without  the  peritoneum  being 
injured,  and  in  all  with  the  most  satisfactory  result.  The  fibrous 
tumors  which  I  exhibit  resemble  one  another  very  closely  both  in 
size  and  appearance.  This  was  a  uterine  polypus,  and  was  re- 
moved by  Dupuy tren's  knot-tightener,  to  which  a  strong  silver  wire 
was  attached,  and  that  an  ovarian  tumor,  which  was  removed  at  the 
request  of  the  patient  by  making  an  incision  through  the  abdominal 
parietes  directly  over  the  tumor,  which  when  exposed  was  detached 
from  the  surrounding  parts,  and  after  the  pedicle  was  ligated  it  was 
removed.  Both  the  pedicle  and  ligature  were  allowed  to  remain  ex- 
ternally, and  the  patient  not  only  recovered,  but  has  since  given  birth 
to  two  healthy  children. 

This  sac  contains  a  fibro-cartilaginous  tumor,  which  is  usually 
called  enchondroma.  This  is  a  correct  likeness  of  the  brave  but 
unfortunate  young  man,  which  was  taken  only  a  few  days  before  the 
operation  was  performed.  The  tumor  extended  from  the  umbilicus 
to  the  axilla,  involved  four  ribs,  and  weighed  sixteen  pounds.  In- 
feriorly  it  was  located  between  the  abdominal  muscles  and  perito- 
neum, from  which  it  was  with  great  difficulty  detached.  When  that 
part  of  the  operation  was  completed,  I  found  that  four  of  the  ribs 
were  involved,  being  greatly  enlarged,  cartilaginous,  and  constitu- 
ting the  greater  portion  of  the  superior  two- thirds  of  the  tumor. 
When  they  were  removed  the  cavity  of  the  chest  was  necessarily 
exposed,  and  the  left  lung  collapsed.  Neither  the  peritoneum  nor 
pleura  were  wounded,  but  the  latter  sloughed  some  days  afterward, 
so  as  to  expose  the  heart.  I  entertained  strong  hope  of  his  recovery 


LECTURE    X.  —  ENCHONDROMA. 


125 


until  peritonitis  occurred,  which  proved  fatal  on  the  sixteenth  day. 
For  thirteen  days  his  appetite  was  good ;  the  action  of  the  heart  was 
but  little  increased.  He  breathed  easily,  and  was  always  cheerful 


FIG.  33. 


and  comfortable,  until  at  the  time  specified  he  was  attacked  with 
acute  pain  in  the  abdomen,  accompanied  with  vomiting,  a  small 
rapid  pulse,  and  all  the  symptoms  of  acute  peritonitis.  This  case 
was  published  in  the  Pacific  Medical  Journal  with  all  the  necessary 
details. 


126  LECTURES    ON    PRACTICAL    SURGERY. 

Disintegration  has  commenced  in  the  inferior  portion  of  the  tumor, 
but  the  remainder  presents  all  the  peculiarities  of  an  enchondroma. 

Recently  I  removed  in  this  city  a  tumor  of  this  character,  which 
involved  the  lower  two-thirds  of  the  scapula,  as  well  as  a  large  en- 
cephaloid  growth,  which  extended  into  the  axilla.  The  cartilaginous 
tumor  made  its  appearance  twenty  years  ago,  in  the  State  of  New 
York ;  it  was  then  removed,  and  until  recently  the  patient  considered 
himself  permanently  relieved.  After  it  made  its  appearance  the 
second  time  it  not  only  increased  rapidly,  but  also  became  exces- 
sively painful.  To  the  anterior  portion  of  the  tumor  was  attached 
an  encephaloid,  which  was  painful  in  consequence  of  the  distension 
of  the  muscles  under  which  it  was  situated.  The  wound  healed 
readily,  and  in  about  six  months  he  returned  with  an  encephaloid 
tumor  larger  than  the  one  which  had  been  removed.  That  was 
operated  upon,  as  there  had  been  a  great  improvement  in  his  general 
health,  and  a  few  days  since  I  had  the  pleasure  to  meet  with  him  in 
my  office  in  perfect  health,  a  year  and  a  half  having  elapsed  since 
the  last  operation  was  performed.  The  last  tumor  removed  was  pro- 
nounced encephaloid  by  the  best  microscopist  of  our  city. 

Treatment. — Many  fibrous  tumors  can  be  removed,  provided  the 
operation  be  performed  before  they  assume  a  malignant  character, 
and  will  not  return.  When  an  entire  bone  is  implicated,  the  dis- 
eased part  should  be  removed,  even  if  a  whole  extremity,  the  su- 
perior or  inferior  maxillary  bones,  the  clavicle,  or  even  the  scapula 
be  involved. 

Keloid. — These  have  been  so  called  in  consequence  of  their  sup- 
posed resemblance  to  a  crab.  Being  more  intimately  connected  with 
fibrous  than  any  other  variety  of  tumor,  and  as  they  occasionally  be- 
come malignant,  they  very  properly  occupy  the  position  in  which 
they  are  placed.  In  structure  they  resemble  the  fibro-plastic  tumor, 
and  vary  in  size  from  that  of  a  chestnut  to  a  man's  fist,  and  gener- 
ally they  increase  more  rapidly  in  length  than  in  magnitude.  They 
resemble  both  in  appearance  and  firmness  the  cicatrix  of  a  burn, 
and  when  a  strong  predisposition  exists  to  this  disease,  all  that  is 
necessary  to  produce  them  is  to  remove  the  cuticle.  Negroes,  who 
have  a  smooth,  soft  skin,  are  much  more  liable  to  this  disease  than 
any  of  the  other  varieties  of  the  human  family.  Before  leaving 
South  Carolina  I  examined  a  healthy  young  colored  man,  whose 
body  was  covered  with  them,  wherever  the  skin  was  subjected  to 


LECTURE    X. KELOID.  —  EPITHELIOMA.  127 

the  friction  of  the  suspenders,  the  waistband  of  the  pantaloons,  or 
the  contents  of  the  pockets,  or  was  accidentally  injured.  In  Cali- 
fornia it  is  a  very  rare  disease ;  I  have  met  with  only  one  case  in  the 
State.  I  treated  a  case  in  South  Carolina  in  which  a  tumor  of  this 
character  became  cancerous,  and  ultimately  proved  fatal  after  being 
several  times  removed. 

Keloid  is  not  amenable  either  to  internal  or  external  treatment. 
The  first  case  of  this  character  upon  which  I  operated,  resulted  from 
the  introduction  of  a  seton  in  the  back  of  the  neck.  The  tumor  was 
carefully  removed,  the  wound  was  closed  by  the  interrupted  suture, 
and  in  five  or  six  days  the  union  was  perfect,  but  from  that  time  the 
cicatrix  appeared  gradually  to  widen  and  enlarge,  and  in  two  months 
a  tumor  existed  larger  than  the  one  previously  excised.  I  then  de- 
termined never  to  interfere  with  such  tumors  again,  and  consequently 
have  always  refused  to  subject  such  -patients  to  surgical  treatment. 

Epithelioma  or  cancroid  is  usually  located  either  upon  the  skin  or 
mucous  membrane,  and  occurs  most  frequently  on  the  under  lip,  the 
nose,  eyelids,  upper  part  of  the  face,  scrotum,  anus,  and  uterus, 
although  it  appears  occasionally  upon  every  portion  of  the  body. 
It  sometimes  commences  upon  the  under  lip  as  a  simple  fissure,  which 
deepens  gradually;  the  edges  become  indurated  and  everted,  and  the 
surface  presents  an  unhealthy  appearance.  Occasionally  a  dark  scale 
appears  upon  the  nose  or  upper  part  of  the  face,  particularly  of  old 
people,  which,  if  irritated,  rapidly  increases  in  size  until  it  presents 
the  appearance  above  indicated.  More  frequently,  however,  a  small 
firm  tubercle  appears,  which  soon  ulcerates,  and  although  it  may 
spread  very  slowly,  will  ultimately,  if  neglected,  involve  the  lym- 
phatic ganglia  in  the  vicinity,  which  is  soon  followed  by  the  can- 
cerous cachexia,  which  indicates  the  existence  of  an  incurable  consti- 
tutional disease.  The  basis  of  these  tumors  is  fibrous,  to  which  the 
condensed,  numerous  and  morbid  epithelial  scales  closely  adhere. 
In  appearance  the  scales  resemble  those  of  the  epidermis,  with  the 
exception  that  their  arrangement  is  different.  Sometimes  these  scales 
are  intermixed  with  globular  bodies,  and  in  other  cases  with  cells 
which  resemble  those  of  true  malignant  cancer.  The  treatment  of 
epithelioma  is  exceedingly  satisfactory,  except  when  it  has  been  neg- 
lected until  the  ganglia  in  the  vicinity  have  become  enlarged  and 
indurated,  and  the  cancerous  cachexia  has  made  its  appearance,  for 
the  removal  of  which  no  remedy  has  yet  or  will  most  probably  ever 


128 


LECTURES    ON    PRACTICAL    SURGERY. 


be  discovered.  When  external  they  should  be  removed  with  the 
knife,  provided  that  can  be  accomplished  without  incurring  the  risk  of 
a  fatal  haemorrhage.  I  repeat,  that  the  treatment  of  epithelioma  is 
exceedingly  satisfactory,  even  when  the  under  lip,  the  eyelids,  and 
other  important  portions  of  the  body  are  involved;  if  properly  re- 
moved they  seldom  return.  When  located  upon  the  under  lip,  and 
not  more  than  an  inch  is  implicated,  a  V-shaped  portion,  including 
the  tumor,  should  be  removed,  and  the  wound  dressed  as  directed 
when  the  operation  was  described.  Should  it  become  necessary  to 
remove  so  much  of  the  lip  as  to  render  the  mouth  inconveniently 


FIG.  34. 


small,  it  may  be  enlarged,  and  the  wound  of  the  under  lip  covered 
with  mucous  membrane  by  dividing  the  latter  a  quarter  of  an  inch 
higher  than  the  integument  and  muscles,  which  should  be  placed 


LECTURE    X.  —  EP1THELIOMA. 


129 


and  secured  under  the  everted  membrane  until  it  adheres.  This 
operation  was  performed  upon  one  of  the  graduates  of  our  college 
six  years  ago  with  the  most  satisfactory  result. 


FIG.  35. 


FIG.  3!. 


130 


LECTURES    ON    PRACTICAL    SURGERY. 


When  the  entire  lip  is  involved,  which  is  not  unfrequent,  it  should 
be  removed,  and  the  deficiency  supplied  either  by  dissecting  up  a 
portion  of  the  integument  in  the  vicinity,  corresponding  in  shape 
with  that  removed,  or  by  detaching  the  skin  from  the  chin  and 
superior  portions  of  the  neck  to  the  width  of  that  removed,  and 
elevating  it  sufficiently  to  supply  the  deficiency.  By  examining  Figs. 
34,  35,  36,  37,  you  can  form  an  idea  of  the  probable  result  of  such 
an  operation  when  properly  performed. 


FIG.  37. 


In  Fig.  34  the  flap  was  taken  from  one  side  of  the  face,  the  size 
being  determined  by  a  pattern  cut  out  of  blotting-paper  after  the  dis- 
eased portion  was  removed.  The  extremity  of  the  flap  sloughed, 
although  a  sufficient  quantity  remained  healthy  to  remove  the  de- 


LECTURE    X.  —  EPITHELIOMA. 


131 


formity.     The  photograph  was  taken  only  a  few  days  after  the  opera- 
tion was  completed,  and  before  the  tumefaction  subsided. 

In  Fig.  36  the  entire  lower  lip  was  removed,  and  a  flap  was 
raised  from  each  side,  and  united  in  the  centre  and  inferiorly.  This 
patient  after  the  operation  disappeared  for  fifteen  days,  lived  as  usual, 
and  when  he  returned,  even  under  such  disadvantages  the  union  was 
complete.  It  is  always  better  to  remove  the  pedicle  as  close  to  the 
face  as  possible,  and  allow  the  wound  to  heal  by  granulation,  than 
to  replace  it  after  it  has  been  reduced  to  the  proper  size  and  shape 


FIG 


to  supply  the  deficiency.  The  sutures  should  neither  be  removed, 
nor  the  operation  completed  before  the  seventh  day,  lest  the  entire 
flap  may  slough,  and  a  failure  result. 

In  Fig.  37,  the  upper  and  lower  lips  were  both  implicated,  and 
the  flap  was  taken  from  the  side  of  the  face ;  but  notwithstanding 
the  operation  was  followed  by  erysipelas,  the  entire  wound  healed  by 
the  first  intention,  and  when  the  operation  was  finished,  but  little 


132 


LECTURES    ON    PRACTICAL    SURGERY. 


deformity  remained.  The  result  in  this  case  was  not  only  gratify- 
ing, but  also  very  extraordinary,  and  proves  conclusively,  that  in 
California  plastic  operations  will  succeed  as  well  as  in  any  other 
climate  or  country,  when  skilfully  performed,  although  a  contrary 
opinion  has  not  only  been  expressed,  but  also  published  in  a  medi- 
cal journal  of  this  city. 

In  Fig.  39  the  tumor  involved  the  entire  under  lip  of  a  man 


FIG.  39. 


seventy-nine  years  old.  After  it  was  removed  a  perpendicular  in- 
cision downward  was  made  on  each  side,  and  the  skin  dissected  up 
to  a  sufficient  extent,  when  raised  and  secured  by  sutures,  to  supply 
the  deficiency  ;  in  five  days  he  returned  to  his  friends,  and  but  little 
if  any  deformity  resulted  from  the  operation. 

Fig.  40  represents  another  case  in  which  the  lower  lip  was  removed 
(Fig.  41),  and  a  flap  raised  from  either  side  to  supply  the  deficiency. 

In  Fig.  43  you  will  find  the  result  of  an  operation  to  replace  the 
eyelids  destroyed  by  an  epithelioma  (Fig.  42).  The  flap  was  taken 


LECTURE    X. EPITHELIOMA. 


138 


from  the  temple,  and  adhered  perfectly  ;  the  eyeball  was  covered  and 
protected,  alt  hough  the  upper  lid  is  unnaturally  low,  which  would  have 


Fro.  40. 


been  relieved  if  erysipelas  had  not  followed  the  second  operation,  and 
rendered  the  postponement  of  the  effort  necessary.     These  cases  have 


FIG.  41. 


all  been  published  in  the  San  Francisco  Medical  Journal,  with  the 
necessary  details,  and  are  only  a  few  of  the  plastic  operations  which 
I  have  performed  in  California  to  remove  deformities,  and  which  have- 


134 


LECTURES  ON  PRACTICAL  SURGERY. 


invariably  been  successful.  The  result  is  attributable  not  only  to 
the  fact  that  the  flap  was  always  made  so  long  that  strangulation 
was  rendered  impossible,  but  also  to  the  use  of  the  warm- water 


FIG.  42. 


dressing,  and  to  the  silver  sutures  being  allowed  to  remain  from 
seven  to  ten  days  before  the  flap  was  detached  and  the  operation 
completed. 

Malignant  Tumors. — Tumors  of  this  character,  even  if  treated 
early  and  properly,  have  not  only  an  inherent  and  decided  tendency 
to  return,  but  their  composition  is  different  from  that  of  any  of  the 
healthy  tissues  of  the  body.  They  present  four  varieties. 

1st.  Colloid  or  gelatinous. 
2d.  Encephaloid  or  soft. 
3d.  Scirrhus  or  hard  cancer. 
4th.  Melanesia. 


LECTURE    X.  —  COLLOID    TUMORS. 


135 


Colloid. — This  variety  is  rare,  and  I  can  present  but  one  specimen. 
It  derives  its  name  from  its  resemblance  to  glue,  and  is  composed 
of  small  and  distinctly  formed  cells  with  the  fluid  already  specified. 


FIG.  43. 


It  seldom  acquires  the  magnitude  of  an  encephaloid,  increases  less 
rapidly,  and  is  not  so  liable  to  return. 

The  specimen  exhibited  was  removed  from  the  base  of  the  tongue 
of  a  young  man  from  Calaveras  County,  in  this  State,  six  or  seven 
years  ago,  with  an  ecraseur  (Figs.  44, 45).  To  prevent,  as  I  supposed, 
the  possibility  of  haemorrhage,  the  lingual  artery  was  ligated  a  week 
before.  The  tongue  being  placed  under  the  control  of  the  surgeon,  by 
passing  a  strong  ligature  through  the  centre  from  below  upward,  a 
transverse  incision  was  then  made,  commencing  an  inch  from  the  ex- 
tremity and  terminating  at  the  median  line,  and  then  a  perpendicular 


136 


LECTURES    ON    PRACTICAL    SURGERY. 


incision,  commencing  at  that  point,  extended  to  the  base.  The  ordi- 
nary ecraseur  was  then  applied,  as  represented  in  Fig.  45,  and  half  a 
turn  of  the  screw  made  every  thirty  seconds  until  the  tumor  was 
detached.  In  about  two  hours  hemorrhage  supervened  from  the 


Fro.  44. 


anterior  portion  of  the  tongue,  furnished  by  the  vessels  of  the  oppo- 
site side,  which  it  required  the  use  of  the  actual  cautery  to  control. 
At  the  expiration  of  two  years  a  tumor  of  the  same  character  made 
its  appearance  upon  the  opposite  side  of  the  tongue,  involving 
the  base  of  the  entire  organ,  and  was  removed  by  a  strong  ligature 
placed  below  the  tumor  by  the  use  of  a  large  curved  needle,  after 
the  cheek,  from  the  angle  of  the  mouth  to  the  last  molar  tooth,  had 
been  divided.  On  the  sixth  day  the  entire  tongue  sloughed,  and  the 
patient,  who  was  too  brave  to  deserve  such  a  fate,  died  on  the  tenth 
day,  which  is  probably  as  favorable  a  result. as  can  be  expected  from 
such  an  operation.  This  case  was  published  in  the  Pacific  Medical 
Journal. 

Encephaloid   or  Medullary  Sarcoma. — The   term    encephaloid  is 


LECTURE    X. ENCEPHALOID. 


137 


employed  in  consequence  of  the  striking  resemblance  of  the  substance 
of  these  tumors  to  brain,  both  in  appearance  and  chemical  compo- 
sition. In  color  it  is  either  white  or  reddish.  Numerous  septa  exist, 
and  the  contents  of  the  cavities  vary  in  density.  These  tumors 
occur  frequently  in  young  persons,  and  then  increase  in  size  very 
rapidly.  They  are  always  elastic,  and  the  superficial  veins  some- 


FIG.  45. 


times  become  greatly  enlarged.  The  elasticity  is  often  mistaken  for 
fluctuation,  and  an  incision  made  suitable  for  opening  an  abscess.  A 
case  occurred  recently  in  this  city  from  a  contusion  on  the  hip, 
and  when  the  tumor  was  removed  three  months  afterwards,  it 
weighed  seven  pounds  and  three-quarters,  and  had  been  opened  by 
a  physician  who  mistook  it  for  an  abscess. 

This  is  an  exceedingly  malignant  tumor,  as  much  so  as  scirrhus, 
and  much  more  rapid  in  its  development.     I  always  operate  in  such 


138  LECTURES    ON    PRACTICAL    SURGERY. 

cases  with  great  reluctance,  as  the  disease  has,  except  in  one  instance, 
always  returned.  You  will  find  numerous  specimens  of  this  morbid 
growth  in  the  museum  of  the  college.  When  removed,  the  disease 
usually  reappears  externally,  although  occasionally  some  internal  and 
vital  organ  becomes  implicated. 

Scirrhus,  or  carcinomatous  sarcoma,  occurs  very  frequently,  and 
derives  its  name  from  its  excessive  hardness.  The  induration  is  not, 
however,  after  the  tumor  has  existed  for  several  months,  uniform. 
These  growths  are  not  only  very  firm  and  heavy,  but  also  excessively 
painful.  The  surrounding  parts  soon  become  implicated,  and  par- 
ticularly the  lymphatic  ganglions.  The  skin  generally  adheres 
firmly  to  the  tumor,  finally  ulcerates,  and  then  it  is  called  an  open 
cancer.  Its  progress  is  less  rapid  than  encephaloid  or  melanosis, 
but  its  consequences  are  equally  serious.  After  ulceration  takes 
place  the  skin  assumes  a  dark  leaden  hue,  which  is  proof  positive 
that  the  disease  has  become  both  constitutional  and  incurable. 

The  fourth  and  last  variety  of  malignant  tumor  is  melanosis. 
This  jar  contains  the  best  specimen  I  have  seen.  It  is  irregular  in 
shape,  and  nearly  black,  from  which  peculiarity  it  receives  its  name. 
The  small  tumor  exhibited  was  developed  on  the  wrist;  the  large 
one  subsequently  came  in  the  axilla  of  the  same  side,  and  increased 
with  as  much  rapidity  as  an  encephaloid.  They  were  both  removed 
at  the  same  time,  and  the  patient  went  home  apparently  relieved, 
but  the  disease  returned  in  the  cavity  of  the  thorax,  and  speedily 
proved  fatal.  These  tumors  differ  from  the  other  varieties  in  color; 
they  generally  occur  in  the  decline  of  life,  and  are  always  incurable. 
Microscopists  think  that  every  variety  of  malignant  tumor  is  com- 
posed of  the  same  elements,  although  differently  arranged,  and  vari- 
able in  proportion.  "  In  all  there  is  a  fibrous  stroma  or  basis,  firmer 
and  closer  in  some,"  as  in  scirrhus,  than  in  others.  This  yields  by 
pressure  or  scraping  a  turbid  juice,  termed  the  cancer-juice,  in  which 
granules,  cells,  pigmentary  and  fatty  matters  are  found  in  varying 
proportions.  The  granules  are  minute,  sometimes  amorphous,  at 
others  presenting  that  peculiar  vibratory  condition  termed  the  mo- 
lecular movement ;  they  are  met  with  in  all  the  varieties  of  cancer, 
although  they  occur  in  the  largest  quantities  in  scirrhus.  The  cells, 
to  which  great  importance  has  been  attached  by  various  observers, 
and  which  have  often  been  looked  upon  as  characteristic  or  pathogno- 
monic  of  the  disease,  though  erroneously  so  in  the  strict  acceptation 


LECTURE    X.  —  TREATMENT    OF    CANCER.  139 

of  the  term,  present,  however,  such  peculiar  appearances  that  it  is 
almost  impossible  to  mistake  them.  They  are  large,  spherical,  fusi- 
form, or  spindle-shaped,  elliptic  or  caudate,  having  often  two  or  three 
terminations,  are  usually  compound,  granular,  have  large  nuclei,  and 
prominent  well-marked  nucleoli.  These  appearances  are  presented 
by  them  in  all  forms  of  the  disease.  It  is,  however,  more  especially 
in  the  encephaloid  variety  that  they  assume  a  large  size,  and  present 
their  most  marked  fusiform  and  caudate  shapes. 

The  pigrnentous  cells  are  principally  if  not  altogether  found  in 
melanosis.  The  value  of  these  microscopic  investigations  is  differ- 
ently estimated  by  surgeons,  and  I  must  confess  that  from  the  mis- 
takes made  by  the  professed  microscopists  of  this  city,  I  place  more 
confidence  in  a  diagnosis  derived  from  the  external  indications  com- 
bined with  the  constitutional  condition  of  the  patient,  than  from  the 
microscopical  appearances,  even  when  observed  by  the  most  experi- 
enced. An  able  surgeon  rarely  commits  an  error  in  diagnosis,  but 
either  microscopists  often  err,  or  these  tumors  are  not  as  malignant 
as  surgeons  generally  believe. 

Treatment. — This  should  be  both  general  and  local.  The  consti- 
tutional remedies  are  confined  to  those  which  are  calculated  to  re- 
lieve pain,  allay  irritation,  support  the  strength,  and  thereby  prevent 
the  rapid  increase  of  the  local  difficulty.  A  mild  but  nutritious  diet 
should  be  prescribed,  and  stimulants  avoided,  except  where  great 
prostration  exists.  Opium  or  some  of  its  preparations  should  be 
administered  freely  at  night,  in  order  that  sufficient  sleep  may  be 
obtained.  Should  the  preparations  of  opium  when  taken  into  the 
stomach  have  a  contrary  effect,  then  it  should  be  applied  either  en- 
dermically  or  hypodermically  as  the  patient  may  prefer,  or  codeia, 
hyoscyamus,  lupulin,  or  brandy  should  be  substituted.  The  latter 
is  in  some  cases  the  best  narcotic  that  can  be  administered.  Pain 
must  be  relieved,  and  sleep  procured,  in  order  to  arrest  the  progress 
of  any  disease,  whether  it  be  simple  or  malignant. 

The  local  treatment  is  much  more  important  than  the  constitu- 
tional. The  part  should  be  kept  at  rest,  and  in  the  most  favorable 
position.  No  applications  should  be  made,  except  those  which  soothe 
without  irritating  the  integument.  If  the  vessels  in  the  vicinity  are 
distended,  accompanied  with  the  other  indications  of  inflammation,  a 
few  leeches  may  be  applied  advantageously,  but  not  to  the  tumor. 
Counter-irritants  should  be  avoided,  and  the  extract  of  either  stra- 


140  LECTURES    ON    PRACTICAL    SURGERY. 

monium  or  belladonna,  or  the  soap  and  lead  plaster  substituted.  After 
ulceration  has  occurred  the  part  should  be  dressed  twice  in  twenty- 
four  hours,  and  the  disagreeable  smell  removed  by  the  use  of  three 
ounces  of  the  chlorate  of  potash  to  a  quart  of  water,  Labarraque's 
solution  of  the  chloride  of  soda,  the  permanganate  of  potash,  or  car- 
bolic acid.  I  prefer  the  chlorate  of  potash,  because  it  is  less  un- 
pleasant and  equally  effectual. 

Escharotics  have  been  and  are  still  employed  for  the  cure  of 
cancers.  The  articles  used  are  mineral  acids,  caustic  potash,  and  ar- 
senic. Except  the  acids,  the  best  is  zinc  paste,  which  is  composed  of 
equal  parts  of  chloride  of  zinc  and  flour,  and  should  be  allowed  to 
remain  twenty-four  hours,  during  which  time  it  will  destroy  an  inch 
and  a  half  in  thickness.  Arsenic  is  the  active  ingredient  in  most  of 
the  local  remedies  used  to  cure  cancer.  It  is  exceedingly  dangerous, 
and  should  never  be  prescribed. 

In  small  superficial  epithelial  ulcers  located  upon  the  nose  or  face, 
nitric  acid  or  the  acid  nitrate  of  mercury  may  sometimes  be  used 
successfully,  but  generally  the  knife  is  decidedly  preferable  to  any 
other  remedy,  and  should  be  resorted  to  before  the  disease  becomes 
constitutional.  When  the  lymphatic  ganglions  are  enlarged  and 
indurated,  or  when  more  than  one  tumor  exists,  I  would  advise  you 
never  to  use  the  knife  except  with  the  understanding  that  it  can  only 
afford  temporary  relief.  Should  either  the  cancerous  diathesis  exist, 
or  it  be  impossible  to  remove  the  entire  morbid  growth,  then  do  not 
recommend  an  operation,  and  only  perform  one  at  the  earnest  solici- 
tation either  of  the  patient  or  his  friends,  because  when  the  disease 
returns  they  are  always  dissatisfied  if  an  operation  has  been  recom- 
mended. 


LECTURE    XI.  —  SCROFULA.  141 


LECTURE   XL 

GENTLEMEN  :  To-day  we  have  before  us  one  of  the  most  difficult 
and  important  subjects  in  Surgery,  and  one  that  should  interest 
every  member  of  the  class.  Scrofula  prevails  everywhere ;  the  in- 
habitants of  the  East  and  West  Indies,  according  to  Major  McCul- 
lough's  report,  being  more  obnoxious  to  the  disease  than  those  of 
British  America,  or  any  portion  of  Europe.  It  may  be  defined  as  a 
peculiar  constitution,  which,  when  fully  developed,  is  characterized 
by  the  formation  of  tubercle.  All  who  inherit  this  peculiarity  of 
constitution,  which  is  called  the  scrofulous  diathesis,  do  not  suffer 
from  its  consequences,  but  may  escape  by  proper  management  even 
when  the  predisposition  is  decided.  I  know  a  lady  in  this  city,  who 
lost  her  mother  by  consumption,  in  whom  the  predisposition  was 
strongly  marked  from  the  period  of  her  birth  until  she  was  fully 
matured.  The  lymphatic  ganglions  of  her  neck  were  enlarged,  she 
suffered  occasionally  fro  u  ulceration  of  both  the  cornea?  and  tonsils, 
as  well  as  from  other  evidences  of  constitutional  debility,  yet  by 
constant  care,  and  prompt  and  proper  treatment,  the  difficulty  was 
overcome,  and  she  is  now  the  mother  of  seven  children,  and  in  the 
enjoyment  of  perfect  health. 

The  scrofulous  diathesis  should  not  be  confounded  with  a  general 
delicacy  of  constitution.  We  often  meet  with  persons  who  are  thin, 
delicate,  and  irritable,  but  otherwise  healthy.  They  are  not  predis- 
posed to  scrofula,  but  have  inherited  the  nervous  temperament,  which 
is  exceedingly  common  in  large  cities.  Berard  in  his  lectures  on 
physiology  stated  to  the  class,  that  if  it  were  not  for  the  emigration 
to  Paris  from  the  provinces,  all  the  inhabitants  of  that  city  would  in 
three  or  four  generations  present  the  peculiarities  characteristic  of 
the  nervous  temperament.  The  human  race  deteriorates  both  physi- 
cally and  mentally  in  large  cities,  and  consequently  becomes  more 
liable  to  scrofula.  There  are  certain  indications  by  which  you  can 
determine  the  existence  of  this  predisposition.  The  str unions  con- 
stitution or  peculiarity  assumes  two  distinct  forms,  and  they  present 
each  one  variety. 


142  LECTURES    ON    PRACTICAL    SURGERY. 

In  the  first  and  most  common  form  the  physical  development  is 
sometimes  extraordinarily  perfect,  bat  usually  it  is  rather  delicate. 
The  subjects  of  it  have  light  hair,  fair  complexion,  florid  cheeks, 
white  teeth,  and  mentally  they  are  generally  precocious. 

In  this  variety  the  skin  is  white  and  exceedingly  coarse,  and  there 
is  a  tendency  to  acne.  The  fingers  are  large  and  blunt,  and  seldom 
well  formed,  although  they  may  possess  great  strength.  The  eves 
are  usually  gray  and  the  hair  curly.  In  persons  of  this  tempera- 
ment, when  tubercles  are  developed,  the  disease  runs  its  course  with 
great  rapidity. 

It  is  generally  believed  that  scrofula  is  confined  to  persons  of  fair 
complexion,  etc.,  but  that  is  not  true,  for  you  will  frequently  meet 
with  those  of  a  dark  complexion,  black  hair  and  eyes,  who  present 
the  same  predisposition. 

In  the  second  form  we  include  persons  who  are  dark,  with  black  eyes, 
and  are  exceedingly  sprightly,  intelligent,  and  even  precocious.  In 
this  variety  the  skin  is  dark  and  rough,  the  eyes  are  black  and  dull, 
and  they  are  remarkable  neither  for  physical  strength  nor  intellect. 
Whenever  the  strumous  diathesis  is  decided,  and  the  skin  fair,  upon 
inquiry  you  will  find  that  the  digestive  organs  are  weak,  and  the 
tongue  presents  the  pipped  or  strawberry  appearance,  so  called  from 
the  existence  near  its  root  of  numerous  red  pimples.  The  edges  of 
the  organ  are  red,  and  the  bowels  irritable ;  there  is  often  trouble- 
some diarrhoea.  Persons  with  a  dark  complexion  who  are  predis- 
posed to  scrofula,  frequently  suffer  greatly  from  constipation,  and 
the  peculiar  appearance  of  the  tongue  described  rarely  exists.  Occa- 
sionally, however,  the  rough  jagged  appearance  of  that  organ  may 
exist  in  other  than  scrofulous  subjects,  but  it  is  almost  always  in- 
dicative of  derangement  of  the  digestive  organs.  Scrofula  appears 
most  frequently  in  the  skin,  mucous  membrane,  bones,  and  joints. 
In  this  city  every  physician  who  has  an  extensive  practice  will  meet 
every  day  with  fair,  light-haired  children,  who  have  eczema  of  the 
scalp,  which  is  always  of  a  scrofulous  character,  and  frequently  when 
neglected  extends  to  the  entire  body.  In  other  cases  ulcers  exist, 
with  bluish  elevated  edges,  and  present  an  unhealthy  and  flabby 
surface,  which  secretes  the  variety  of  purulent  matter  described 
when  that  fluid  was  under  consideration,  and  they  always  heal 
with  great  difficulty.  They  frequently  exist  on  the  neck  of  a 
child  which  presents  the  usual  indications  of  good  health.  The  face 


LECTURE    XI. — SCROFULA.  143 

may  be  large,  plump,  and  florid,  but  you  can  always  find  other  evi- 
dences of  scrofula.  When  the  mucous  membrane  is  implicated,  there 
is  frequently  a  discharge  from  the  ears,  a  thickening  of  the  mucous 
membrane  of  the  nose,  an  enlargement  of  the  tonsils,  prolapsus  ani, 
a  vaginal  discharge,  or  inflammation  of  the  eyelids.  If  the  latter  be 
neglected,  the  lids  may  become  either  inverted  or  everted,  with  a  loss 
of  the  eyelashes,  and  even  of  vision,  and  it  always  produces  perma- 
nent deformity.  Scrofulous  affections  of  the  bones  and  joints  are 
exceedingly  common  in  California,  and  commence  in  the  cancellated 
structure  of  the  bone,  which  constitutes  caries,  or  in  the  periosteum, 
which  usually  results  in  necrosis.  When  this  disease  attacks  the 
joints  it  is  called  white  swelling,  which  may  be  simply  an  inflamma- 
tion and  thickening  of  the  synovial  membrane,  or  it  may  extend  to 
ulceration  and  disorganization  of  that  membrane,  as  well  as  of  the 
cartilages  and  of  the  extremities  of  the  bones. 

The  enlargement  of  the  lymphatic  ganglions  is  so  frequent  that  it 
was  formerly  supposed  to  constitute  and  represent  the  disease,  the 
other  varieties  being  attributed  to  some  other  cause.  They  some- 
times, especially  upon  the  neck,  become  so  enormously  enlarged  as 
to  produce  suffocation.  The  testicles  frequently  become  implicated, 
and  the  enlargement  is  always  characterized  by  excessive  hardness. 
The  organ  becomes  irregular  in  shape,  and  sometimes  the  epididymis 
is  more  diseased  than  the  gland  itself,  although  they  both  finally  be- 
come implicated.  Suppuration  ultimately  takes  place,  and  a  long 
and  properly  directed  course  of  treatment  is  required  to  prevent  dis- 
organization, and  consequently  a  destruction  of  the  function  of  the 
organ. 

Having  enumerated  the  less  important  diseases  which  result  from 
the  scrofulous  diathesis,  I  will  now  direct  your  attention  to  tubercle, 
the  formation  of  which  is  an  evidence  that  it  has  reached  that  too 
often  fatal  point. 

It  is  called  scrofulous  sarcoma,  and  was  not  mentioned  in  my 
lectures  on  tumors  because  it  requires  an  entirely  different  course 
of  treatment.  It  presents  two  varieties  ;  in  one  there  are  granules, 
which  are  hard,  smooth,  and  bear  a  striking  resemblance  to  carti- 
lage. They  are  closely  connected,  arranged  in  groups,  and  are  not 
much  larger  than  the  head  of  a  pin,  and  consist  of  what  is  called 
"modified  exudation-matter;  there  are  abundant  indications  of  in- 
flammatory action  in  the  vicinity,  and  they  have  a  decided  tendency 


144  LECTURES    ON    PRACTICAL    SURGERY. 

to  unite  and  form  the  common  yellow  tubercle,  which  presents  a 
grayish-yellow,  gritty,  semi-organized  mass.  It  imparts  a  gritty 
sensation  to  the  knife  when  cut,  and  after  it  has  existed  for  a  con- 
siderable time  it  breaks  down,  leaving  a  cavity,  which  secretes  a 
curdy,  unhealthy  fluid.  These  deposits  are  found  most  frequently 
in  the  lungs,  although  they  are  occasionally  met  with  in  the  brain, 
upon  the  mucous  membrane  of  the  intestines,  in  the  bodies  of  the 
vertebrae,  the  extremities  of  the  long  bones,  and,  indeed,  there  is 
not  a  tissue  or  organ  of  the  human  body,  whether  external  or  inter- 
nal, in  which  tubercles  may  not  be  deposited.  The  microscopic 
characters  are  not  very  decided.  According  to  Erichsen,  they  con- 
sist of  a  homogeneous  stroma,  a  granular  matter,  which  is  princi- 
pally met  with  in  yellow7  tubercles,  drops  of  molecular  oil,  and, 
lastly,  considerable  quantities  of  imperfectly  developed  exudation- 
cells,  often  angular  or  broken  on  one  side,  more  or  less  disinte- 
grated, stationary,  or  degraded.  Indeed,  we  must  often  recognize 
tubercle  by  its  negative  rather  than  its  positive  characters,  by  as- 
certaining what  it  is  not,  and  so  by  a  process  of  exclusion  arriving 
at  its  true  nature.  It  is  easily  confounded  with  pus,  from  which, 
however,  the  appearances  differ  sufficiently  to  avoid  error  if  a  little 
care  be  taken. " 

This  disease  may  appear  at  any  age,  from  four  months  to  as  many 
score  years.  In  California  some  variety  of  scrofula  may  be  met 
with  every  day  in  children  three  or  four  months  old,  but  usually 
strumous  ophthalmia,  enlargement  of  the  tonsils,  etc.,  occur  most 
frequently  from  one  to  four  years  of  age,  although  it  may  appear  at 
any  subsequent  period,  and  tubercular  phthisis  may  not,  even  when 
there  is  a  constitutional  predisposition,  prove  fatal  before  the  age  of 
sixty-five  or  seventy  years.  Two  members  of  the  same  family,  with 
whom  I  was  intimate,  died  of  consumption,  one  at  sixty  and  the 
other  at  sixty-seven  years  of  age.  They  lived  well,  and  when 
young  took  daily  active  exercise,  and  the  disease  was  only  devel- 
oped when  age  had  rendered  them  indolent. 

The  milder  forms  of  scrofula  are  more  frequent  in  childhood,  but 
the  tubercular  form  generally  occurs  between  sixteen  and  thirty,  and 
more  persons  die  at  twenty-eight  than  at  any  other  period  of  life. 

Causes. — The  most  fruitful  cause  is  unquestionably  hereditary 
predisposition,  or  in  other  words  constitutional  peculiarity,  the  in- 
dications of  which  have  already  been  described,  and  they  may  be 


LECTURE    XI.  —  SCROFULA.  145 

so  decided  that  they  cannot  be  counteracted  by  any  means  that  can 
be  adopted.  Some  suppose  that  the  children  of  dyspeptic  parents, 
of  those  either  not  fully  matured  or  far  advanced  in  life,  are  more 
frequently  scrofulous  than  those  born  under  more  favorable  circum- 
stances. 

A  very  common  exciting  cause  is  improper  food.  It  may  not 
contain  sufficient  nutriment,  or  it  may  be  so  difficult  of  digestion  as 
to  be  incompatible  with  good  health.  Sometimes  by  overfeeding 
the  digestive  organs  become  deranged,  diarrhoea  supervenes,  and  the 
same  effect  is  produced  that  might  be  expected  to  result  from  the 
absence  of  nutriment.  Insufficient  clothing  should  also  be  men- 
tioned as  a  very  common  exciting  cause,  particularly  on  this  coast. 
Here  we  really  have  no  summer.  The  skin,  unless  it  be  well  pro- 
tected during  the  prevalence  of  the  trade-winds,  ceases  to  perform 
its  functions.  The  digestive  organs  become  deranged ;  and  this  is 
all  that  is  necessary  to  produce  the  disease  in  those  who  have  either 
inherited  the  predisposition  or  acquired  it  by  being  exposed  to  the 
causes  which  have  or  will  hereafter  be  enumerated.  The  want  of 
abundant  air  and  light,  particularly  if  combined  with  cold  and 
moisture,  is  in  all  cities  an  exceedingly  prolific  cause  of  disease  of 
this  kind.  The  children  raised  under  such  circumstances  are  deli- 
cate, small,  and  exceedingly  liable  to  the  various  milder  forms  of 
scrofula,  as  well  as  to  curvatures  of  the  spine,  to  disease  of  the  hip- 
joint,  and  when  more  advanced  to  tubercular  consumption.  In 
scrofula  there  is  always  defective  nutrition.  The  digestive  organs, 
therefore,  perform  a  very  important  part  both  in  the  development 
of  the  disease  and  in  its  arrest  and  eradication  after  it  has  super- 
vened. 

Treatment. — Various  remedies  have  been  recommended  in  the 
treatment  of  scrofula,  but  they  are  not  all  equally  efficacious  in  the 
different  varieties,  and  during  their  use  the  strictest  attention  should 
be  paid  to  hygienic  regulations.  The  clothing  should  be  warm,  and 
during  the  summer  months  on  the  Pacific  coast  chamois  leather 
should  be  worn  over  the  flannel,  especially  if  the  digestive  organs 
be  decidedly  deranged.  The  diet  should  be  light  and  nutritious, 
and  taken  only  in  such  quantities  as  can  be  easily  digested.  Rice, 
milk,  eggs,  white  meat,  boiled  fish,  and  the  ordinary  farinaceous 
substances  should  be  prescribed  so  long  as  the  bowels  are  irritable, 
and  all  alcoholic  stimulants  should  be  excluded  from  the  treatment. 

10 


146  LECTURES    ON    PRACTICAL    SURGERY. 

When  this  difficulty  has  been  overcome,  then  a  suitable 'quantity  of 
more  nutritious  food  should  be  allowed,  not  oftener  than  four  times 
in  twenty-four  hours,  for  there  is  nothing  more  injurious  to  children 
than  to  allow  them  to  take  nourishment  before  the  digestion  of  a 
previous  meal  is  completed.  A  small  quantity  of  good  port  wine 
after  meals  should  be  prescribed.  The  exercise  should  be  suited  to 
the  strength  of  the  patient,  and,  when  possible,  taken  in  the  open 
air.  And  even  a  change  of  residence  sometimes  becomes  necessary, 
particularly  if  the  elevation  be  increased  to  from  1500  to  2000  feet 
above  the  level  of  the  sea,  which  climate  appears  to  exert  the  most 
favorable  influence  upon  the  digestive  organs.  Warm  salt-water 
baths  are  also  very  beneficial,  provided  proper  precautions  be  taken 
to  insure  reaction,  without  irritating  the  skin  by  excessive  friction 
with  coarse  towels  or  other  abominations  in  the  shape  of  hair  gloves, 
straps,  and  brushes. 

When  the  digestive  organs  of  scrofulous  children  are  deranged, 
especially  if  diarrhoea  exists,  and  the  tongue  is  furred,  with  red  edges, 
half  a  grain  of  calomel  should  be  given  at  night,  until  the  secretions 
of  the  liver  and  the  mucous  membrane  of  the  intestinal  canal  become 
healthy,  and  then  the  following  preparation,  if  proper  attention  be 
paid  to  diet,  will  be  found  exceedingly  beneficial.  This  prescription 
is  intended  for  a  child  four  years  old. 

R. —  Bismuthi  Subcarb.,  .         .         .         .         .         .         .  sjij. 

Tinct.  Nucis  Vomiese,      .         .         .  .         .  .^s. 

Syr.  Zingiberis,        .         .         .         .         .  •  ,1J- 

Syr.  Simplicis, ,^iij. 

M.  Sig.  Take  one  teaspoonful  four  times  a  day. 

The  dose  may  be  increased  or  diminished  according  to  the  age  of 
the  patient;  the  dose  for  an  adult  being  four  times  as  large  as  that 
for  a  child  four  years  old,  which  has  been  already  given. 

Scrofulous  children  with  dark  complexions  are  very  liable  to 
strurnous  ophthalmia,  as  well  as  to  an  enlargement  of  the  lymphatic 
ganglions  of  the  neck,  both  of  which  are  accompanied  with  consti- 
pation of  the  bowels.  In  such  cases  I  have  found  the  following  pre- 
scription superior,  as  a  laxative,  tonic,  and  alterative,  to  any  com- 
bination of  remedies  I  have  ever  administered.  This  prescription  is 
intended  for  a  child  four  years  old. 


LECTURE    XI.  —  TREATMENT    OF    SCROFULA.  147 

R.— Ext.  Sennse  Fl., %\v. 

Tinct.  Nucis  Vomicae,          .....  giss. 
Tinct   Aconiti  Kad., 

Ac.  Hydrocyan.,  aa  .         .  .         .  gtt.  xv. 

Syr.  Zingiberis,  .......  ^iss. 

Syr.  Simplicis, Jij. 

M.  Sig.  Take  one  teaspoonful  four  times  a  day. 

Should  the  bowels  remain  constipated,  the  quantity  of  the  senna 
may  be  increased.  It  acts  on  the  liver,  and  exerts  a  decidedly  bene- 
ficial effect  upon  the  mucous  membrane  of  the  stomach  and  bowels. 

For  eczema  of  the  scalp  the  best  local  remedy  is  a  solution  of  the 
supercarb.  soda,  5ij  to  the  quart  of  water.  Three  or  four  doubles 
of  lint  or  old  porous  cloth  should  be  saturated  with  the  solution, 
and  applied  morning  and  evening,  evaporation  being  prevented  by 
the  application  of  oiled  silk  until  the  scabs  are  removed,  and  the 
zinc  or  citrine  ointment  should  then  be  applied.  The  hair  should 
be  kept  very  short  during  the  treatment,  and  the  strictest  attention 
should  be  paid  to  cleanliness,  diet,  exercise,  and  clothing. 

In  strumous  ophthalmia,  in  addition  to  the  constitutional  treat- 
ment, local  remedies  are  necessary,  and  the  best  collyrium  to  remove 
the  excessive  photophobia  that  always  exists  in  such  cases  is  a  solu- 
tion of  the  nitrate  of  silver,  two  grains  to  Sj  of  distilled  water.  Its 
use  should  be  abandoned  as  soon  as  possible,  and  a  solution  of  sulph. 
aluminse,  grs.  v  to  the  Sj  of  distilled  water,  or  some  other  astrin- 
gent substituted,  because  if  the  nitrate  of  silver  be  continued  long, 
it  stains  the  conjunHiva,  and  injures  the  appearance  of  the  eye. 

An  excellent  substitute  in  such  cases  for  the  preparation  before 
given,  particularly  when  the  effect  has  been  diminished  by  repetition, 
is  the  following : 

R. — Quinise  Sulph., 5jj. 

Syr   Khei.  Arom., 

Syr.  Zingiberis,  aa £j. 

Syr.  Simplicis,  ........     ^ij 

M.  Sig.  Give  one  teaspoonful  three  times  daily.   ' 

In  cases  in  which  the  child  is  pale  and  somewhat  emaciated, 
without  the  existence  of  intestinal  irritation,  5\j  of  the  precipitated 
carbonate  of  iron  may  be  added  to  either  of  the  mixtures  with,  in 
many  cases,  the  happiest  result.  I  prefer  this  preparation  of  iron 


148  LECTURES    ON    PRACTICAL    SURGERY. 

for  children  because  it  is  equally  efficacious  and  comparatively  taste- 
less. 

When  the  lymphatic  ganglions,  submaxillary  glands,  or  testicles 
become  enlarged,  the  iodide  of  potassium  is  preferable  to  any  other 
remedy.  It  may  be  combined  with  laxatives  and  tonics  if  necessary. 
3iv  to  §vi  of  syrup  should  be  taken  by  an  adult  three  times  a  day 
in  teaspoonful  doses,  and  one-fourth  the  quantity  to  a  child  four 
years  old.  In  such  cases,  whether  male  or  female,  when  near  or  at 
the  age  of  puberty,  Blancard's  pills  will  be  found  superior  either  to 
the  iodide  of  potassium  or  to  any  preparation  of  iron  separately  ad- 
ministered. The  worst  case  of  enlargement  of  the  ganglions  of  the 
neck  that  I  ever  treated  yielded  in  three  months  to  the  use  of  these 
pills.  Cod-liver  oil  is  highly  recommended  by  many  able  surgeons 
and  physicians,  yet  I  must  say  that  in  such  cases  it  has,  in  my 
hands,  failed  to  produce  the  effect  claimed  for  it  by  its  advocates. 
Few  stomachs  can  retain  it,  and  fewer  still  can  digest  the  quantity 
usually  administered.  For  children,  when  its  protracted  use  is  nec- 
essary, cream  is  preferable.  I  have  taken  it  myself,  but  never  with 
advantage,  as  it  always  deranged  the  stomach  and  acted  as  a  cathartic. 

Local  Treatment. — This  consists  almost  entirely  in  the  use  of  such 
remedies  as  when  properly  applied  will  remove  enlargements  and 
indurations  of  the  parts  implicated.  Equal  quantities  of  the  tinc- 
ture of  iodine  and  tincture  of  arnica  applied  with  a  camel's-hair  pen- 
cil, morning  and  evening,  will  be  found  to  be  exceedingly  valuable. 
When  the  skin  is  delicate,  as  in  children,  5j  of  the  iodide  of  potas- 
sium with  Sj  of  the  spts.  vin.  rectif  and  5xj  or  water,  may  be  ap- 
plied by  saturating  lint  with  the  solution,  and  covering  it  with  oiled 
silk  to  prevent  evaporation.  In  enlargement  and  induration  of  the 
testicle,  the  ungt.  hydrarg.  mitis  will  increase  the  action  of  the  ab- 
sorbents, and  remove  the  difficulty  more  speedily  than  any  other  ap- 
plication that  can  be  made.  When  suppuration  takes  place  the  ab- 
scess should  be  opened  and  treated  as  one  of  a  different  character, 
and  should  the  ulcer  fail  to  cicatrize,  and  a  sinus  remain,  the  cavity 
should  be  filled  with  equal  quantities  of  the  compound  tincture  of 
iodine  and  water,  and  this  allowed  to  escape  after  remaining  five 
minutes. 

Operations  for  scrofulous  affections  should  be  confined  to  the 
bones,  and  should  not  be  performed  until  the  periosteum  is  detached 
and  the  whole  of  the  disease  removed ;  then  the  bone  is  speedily  re- 
produced, and  the  result  is  in  many  cases  really  extraordinary. 


LECTURE    XI.  —  TREATMENT    OF    SCROFULA. 


149 


Fig.  46  represents  the  foot  and  leg  of  a  child  many  of  you  have 
seen,  from  which,  three  years  ago,  all  the  bones  of  the  ankle-joint 
with  three  inches  of  the  lower  extremity  of  the  tibia  were  removed. 


Fie.  46. 


The  limb  is  nearly  as  long  as  the  other;  the  motion  of  the  joint 
is  perfect,  and  with  a  laced  boot  she  walks  with  as  much  ease  and 
as  rapidly  as  any  other  child  of  her  age.  Her  general  health  is  good, 
and  it  is  highly  probable,  with  proper  care,  that  the  difficulty  will 
not  return. 

Fig.  47  represents  the  appearance  of  the  foot  and  leg  of  a  lady 


150 


LECTURES  ON  PRACTICAL  SURGERY. 


about  twenty-eight  years  old,  who  when  operated  upon  weighed  only 
seventy-five  pounds,  being  reduced  by  the  pain  which  resulted  from 
the  extensive  disease  of  the  bones  of  the  ankle-joint,  and  the  pro- 
fuse discharge  inseparable  from  such  a  condition.  In  this  case  all 
the  bones  of  the  ankle  were  removed  through  small  lateral  incisions, 
with  toothed  forceps,  and  about  two  inches  of  the  lower  extremity 
of  the  tibia  and  fibula  with  the  trephine  and  chisel.  All  the  dead 
bone  being  removed,  she  recovered  rapidly,  and  now  does  not  find  it 


FIG.  47. 


necessary  to  use  either  a  stick  or  crutch.  In  such  cases,  unless  the 
patient  is  hopelessly  exhausted,  I  never  amputate  a  limb.  Within 
a  few  months  I  have  saved  a  lad  in  this  city  from  mutilation  by 
simply  removing  the  lower  extremity  of  the  tibia.  The  wound 
healed  in  three  months ;  he  is  now  in  perfect  health,  with  simply  a 
partial  anchylosis  of  the  joint,  which  still  leaves  the  limb  much  more 
useful  than  a  wooden  substitute  would  be. 

In  operations  of  this  character  writers  generally  advise  free  inci- 
sions, but  I  counsel  you  to  pursue  a  different  course.  Make  an  open- 
ing only  large  enough  to  admit  the  forceps  or  trephine,  and  you  will 


LECTURE    XI.  —  TREATMENT    OF    SCROFULA.  151 

always  be  satisfied  with  the  result.  You  may  by  judicious  treat- 
ment, even  where  a  strong  predisposition  exists,  prevent  the  devel- 
opment of  tubercles,  but  when  they  form  in  the  lungs  and  become 
softened,  the  disease  is  incurable,  although  it  may  not  prove  speedily 
fatal.  From  the  rapid  improvement  of  the  general  health  produced 
by  cod-liver  oil  and  other  remedies,  with  change  of  climate,  I  have 
in  a  few  cases  for  a  time  been  almost  induced  to  believe  a  cure  pos- 
sible, but  every  case,  sooner  or  later,  has  resulted  fatally.  A  few 
years  ago  a  young  man,  with  cavities  in  both  lungs,  and  greatly  ema- 
ciated, was  advised  to  spend  his  summer  in  the  Coast  Range,  and  to 
live  on  fish  and  game.  In  a  few  months  he  returned  apparently 
well,  with  the  exception  that  the  cough  remained  and  the  cavities 
still  existed.  Very  soon  he  lost  his  appetite  and  strength,  and  soon 
fell  a  victim  to  the  diarrhoaa  and  exhausting  perspiration  that  always 
exist  in  the  last  stages  of  this  dreadful  disease.  By  living  well  and 
sleeping  in  the  open  air  consumption  may  be  prevented  but  not 
cured.  I  was  long  acquainted  with  a  native  of  New  York,  who  had 
tubercles  in  the  lungs  and  repeated  haemorrhages  for  twenty  years. 
He  was  in  easy  circumstances,  and  consequently  spent  the  summer 
months  in  his  native  State,  and  the  winter  either  -in  the  interior  of 
South  Carolina,  Florida,  or  Louisiana.  The  frequent  changes  kept 
his  general  health  good  and  arrested  the  progress  of  his  disease 
until  he  was  fifty-two  years  old.  Having  a  beautiful  farm  near 
New  York  City,  and  his  condition  being  exceedingly  flattering,  he 
determined  to  remain  there  during  the  winter.  So  soon  as  the 
weather  became  cold  he  was  attacked  with  pneumonia,  by  which  he 
was  confined  to  his  bed  during  the  remainder  of  the  winter,  and 
he  died  soon  after  reaching  Columbia,  South  Carolina,  early  the 
following  spring.  Never  send  a  consumptive  patient  to  a  tropical 
climate,  and  never,  when  in  an  advanced  stage,  to  any  other  place 
except  to  the  home  of  a  relative,  guardian,  or  friend,  unless  they  have 
the  means  to  secure  all  the  attention  such  a  hopeless  and  helpless 
condition  demands. 


i'Y 

VEUSITY  OF 

CALIFOB 


152  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   XII. 

As  previously  announced,  I  will  lecture  to-day  upon  the  arteries. 
There  are  two  great  arterial  trunks  in  the  human  body.  One  con- 
veys the  blood  from  the  right  side  of  the  heart  to  the  lungs,  which 
is  called  the  pulmonary  artery;  its  final  branches  do  not  anastomose, 
and  are  intended  to  expose  the  blood  to  the  action  of  the  atmospheric 
air;  when  oxygenized  it  is  returned  by  the  pulmonary  veins  to  the 
left  side  of  the  heart,  and  from  thence  is  distributed  by  the  aorta 
and  its  branches  to  every  portion  of  the  body.  The  branches  of  the 
pulmonary  artery  not  only  do  not  anastomose,  but  are  also  almost 
entirely  exempt  from  disease.  A  few  months  since  I  examined  a 
man  who  had  an  aneurism  in  the  right  side  of  the  chest,  near  the 
nipple,  and  from  its  position  I  believe  that  one  of  the  branches  of 
the  pulmonary  artery  was  implicated;  even  if  the  diagnosis  was  cor- 
rect, that  case  would  simply  present  an  exception.  The  branches  of 
the  aorta  besides  anastomosing  freely  are  very  liable  to  become  dis- 
eased, consequently  it  is  in  that  vessel  and  its  ramifications  that  we 
are  particularly  interested.  The  arteries  are  composed  of  three 
coats;  1st.  Cellular.  2d.  Muscular.  3d.  Serous.  The  external  or 
cellular  is  dense,  firm,  resisting,  and  flexible.  The  middle,  muscular 
or  elastic  coat  is  both  extensible  and  resilient.  It  yields  readily  to 
pressure,  but  when  that  is  removed  it  speedily  recovers  its  original 
form.  The  internal  or  serous  coat  is  more  delicate  than  the  former, 
and  being  a  serous  membrane  it  is  very  liable  to  inflammation  as  well 
as  to  other  diseases. 

All  the  coats  being  vascular  are  subject  to  disease,  but  when  the 
serous  or  internal  coat  becomes  inflamed,  the  vessel  may  be  obliter- 
ated by  the  effusion  and  organization  of  coagulable  lymph.  The 
same  thing  may  result  from  wounds,  bruises,  or  pressure.  If  long- 
continued  pressure  be  made  upon  an  artery  the  serous  coat  will  in- 
flame, and  the  vessel  be  obliterated  as  already  described.  In  that 
manner  we  sometimes  succeed  in  curing  aneurism,  particularly  if  the 
pressure  be  made  above  the  tumor. 

When  a  large  bloodvessel  is  obliterated,  if  a  proper  course  of 


LECTURE    XII.  —  ARTERIAL    BLEEDING.  153 

treatment  is  not  pursued,  the  parts  which  received  blood  from  the 
vessel  destroyed  may  mortify,  as  in  cases  of  gangrena  senilis,  or  of  the 
application  of  a  ligature  upon  the  main  artery  of  an  extremity.  The 
former  may  result  from  the  deposition  of  calcareous  matter  upon  the 
serous  coat  of  the  vessel,  by  which  the  calibre  of  the  latter  is  so  much 
diminished  that  the  blood  is  excluded  from  parts  which  it  should 
supply.  When  an  extremity  becomes  gangrenous  in  consequence 
of  the  main  artery  being  ligated,  the  only  alternative  left  is  amputa- 
tion. 

Fatty  degeneration  of  the  inner  coats  of  the  artery  is  exceedingly 
common  on  this  coast.  The  vessels  when  weakened  either  by  this  or 
an  atheromatous  condition  dilate  readily,  which  accounts  for  the  fre- 
quent occurrence  of  aneurism  in  this  State.  Calcareous  scales  on  the 
contrary  do  not  render  the  coats  of  the  vessel  less  resisting,  and  I 
have  never  met  with  a  case  of  aneurism  which  resulted  from  that 
cause.  The  obstruction  interferes  seriously  with  nutrition,  but  is 
never  accompanied  with  dilatation.  Injuries  of  the  arteries  consti- 
tute a  very  important  part  of  this  subject.  When  they  are  wounded, 
the  blood  escapes  very  rapidly,  and  flows  either  in  a  continuous 
stream  or  by  jets,  according  to  the  size  of  the  vessel  injured.  If  a 
large  artery  be  wounded,  the  blood  flows  in  an  uninterrupted  stream, 
as  I  had  once  an  opportunity  to  witness  very  unwillingly.  I  was 
amputating  at  the  hip-joint,  and  the  assistant  who  was  expected  to 
control  the  hemorrhage  by  pressure  failed,  and  so  soon  as  the  femo- 
ral artery  was  divided  the  blood  escaped  in  a  continuous  stream, 
and  struck  the  side  of  the  room  at  least  ten  feet  from  the  patient. 
I  caught  the  vessel  with  the  thumb  and  forefinger  of  the  left  hand, 
and  arrested  the  hemorrhage  until  spring  forceps  were  adjusted,  and 
a  ligature  applied.  In  the  completion  of  the  operation  the  arteries 
were  ligated  so  soon  as  they  were  divided,  which  precaution  was 
indispensable  to  its  success.  If  the  wounded  artery  be  small  the 
blood  always  flows  by  jets;  the  loss  is  much  less  rapid,  and  conse- 
quently less  dangerous.  In  all  cases,  even  if  prepared  to  apply  a 
ligature,  arrest  the  hemorrhage  as  speedily  as  possible  by  pressure. 
Take  hold  of  the  vessel  with  spring  forceps  and  apply  a  ligature 
which  corresponds  in  size  with  that  of  the  wounded  vessel.  If  very 
small  a  single  thread  of  silk  will  be  sufficient,  but  if  it  be  the  femoral 
artery  the  ligature  should  be  at  least  four  times  as  large. 


154  LECTURES    ON    PRACTICAL    SURGERY. 

A  great  variety  of  opinions  have  been  entertained  respecting  the 
agents  by  which  haemorrhage  is  arrested. 

Petit  supposed  that  it  resulted  entirely  from  the  coagulation  of  the 
blood,  and  that  the  formation  of  coagulum  commenced  at  the  wound, 
and  gradually  increased  until  the  vessel  was  closed. 

Morand  thought  that  besides  coagulation,  there  was  also  contrac- 
tion of  the  mouth  of  the  vessel,  and  Pouteau,  that  it  resulted  from 
infiltration  of  the  surrounding  tissues.  Dr.  Jones  in  1807  proved 
by  experiments  that  the  process  was  exceedingly  complicated,  and 
did  not  consist  simply  of  either  coagulation,  contraction,  or  infiltra- 
tion into  the  surrounding  tissues,  but  that  in  the  first  place  the  artery 
both  contracts  and  retracts,  in  consequence  of  the  elasticity  of  its 
parietes,  and  particularly  of  the  inner  and  middle  coats.  The  ex- 
ternal being  less  contractile  and  more  unyielding,  projects  beyond 
the  former,  and  presents  a  slight  obstacle  to  the  escape  of  blood. 
Some  adheres  to  the  surface,  and  lessens  the  velocity  of  the  current, 
which  favors  both  infiltration  into  the  surrounding  cellular  tissue 
and  coagulation.  The  latter  commences  on  the  outside  of  the  vessel, 
gradually  extending  to  the  interior  until  the  escape  of  blood  is  ar- 
rested. The  most  important  part  of  the  process  is  yet  to  be  per- 
formed. So  soon  a^  sufficient  inflammation  of  the  internal  coat  can 
take  place,  plastic  lymph  is  effused;  this  becomes  organized,  .and 
closes  the  vessel  permanently.  Plastic  lymph  is  the  great  agent  by 
which  all  bleeding  vessels  are  closed.  Without  it  a  temporary  sus- 
pension would  occur,  but  in  order  that  the  haemorrhage  may  be  per- 
manently arrested,  inflammation  of  the  serous  membrane  must  take 
place,  and  lymph  be  both  effused  and  organized. 

When  an  artery  is  wounded  by  a  cutting  instrument,  the  haemor- 
rhage is  always  profuse  and  obstinate,  which  is  not  usually  the  case 
in  contused  and  lacerated  wounds.  Here  the  loss  of  blood,  even 
when  vessels  of  considerable  magnitude  are  divided,  is  sometimes  so 
trifling  as  to  give  but  little  inconvenience.  In  such  cases  the  exter- 
nal coat,  being  the  last  to  yield,  and  being  less  contractile,  projects 
beyond  the  internal  and  middle,  and  favors  a  speedy  coagulation  of 
the  blood,  by  which  the  haemorrhage  is  temporarily  arrested ;  but  you 
cannot  calculate  upon  its  permanency,  as  the  coagulum  will  be  de- 
tached, and  what  is  called  secondary  haemorrhage  will  supervene, 
unless  plastic  lymph  is  effused  and  organized. 

The  question   now  arises,  what  are  the  best  means  to  control 


LECTURES    XII.  —  HAEMOSTATICS.  155 

haemorrhage  from  a  wounded  vessel  ?  The  first  and  most  simple  is 
pressure;  second,  torsion;  third,  styptics  or  haemostatics;  fourth, 
the  ligature ;  fifth,  the  actual  cautery.  If  the  wounded  vessel  be 
small,  and  located  where  pressure  can  be  made  properly,  it  generally 
obviates  the  necessity  of  resorting  to  other  means.  Should  pressure 
fail,  torsion  may  be  resorted  to,  particularly  if  union  by  the  first 
intention  is  desirable.  It  consists  in  taking  hold  of  the  vessel  with 
spring  forceps,  and  twisting  it  until  the  forceps  are  detached.  Should 
that  method  fail,  then  a  ligature  should  be  applied. 

Although  numerous  haemostatics  were  formerly  recommended  and 
employed,  there  are  only  a  few  that  are  worthy  of  confidence.  In 
epistaxis  the  hemorrhage  can  generally  be  arrested  by  introducing 
wet  lint  covered  with  powdered  alum.  The  sulphate  of  copper  used 
in  the  same  manner  is  more  effectual,  although  more  painful.  The 
most  powerful  remedy  of  that  character  is  Monsel's  salt.  When 
placed  upon  wet  lint,  and  passed  into  the  superior  strait,  and  retained 
by  plugging  the  nasal  cavity  effectually,  it  never  fails  to  produce  the 
desired  effect.  I  have  never  found  it  necessary,  in  a  case  of  this 
character,  to  use  Bellocq's  sound,  having  been  able  in  every  case  to 
relieve  the  patient  by  less  disagreeable  remedies.  I  prefer  the  alum 
in  ordinary  cases,  because  it  is  much  less  unpleasant  than  the  other 
articles  specified,  and  has  never  failed  to  produce  the  desired  effect. 

In  wounds  upon  the  hands,  feet,  or  any  other  portion  of  the 
body  where  pressure  can  be  combined  with  a  haemostatic,  I  prefer 
the  Monsel's  salt,  and  with  it,  if  it  can  be  applied  to  the  mouth  of 
the  bleeding  vessel,  you  can  control  a  haemorrhage  from  either  the 
radial  or  ulnar  arteries.  It  is  not  simply  an  astringent,  but  it  also 
coagulates  the  blood  instantaneously,  which  renders  it  necessary  be- 
fore the  application  is  made  that  the  haemorrhage  be  arrested  by 
pressure  above  the  wound,  and  all  the  coagulated  blood  removed, 
so  that  the  salt  may  come  in  contact  with  the  wounded  vessel.  The 
coagulum  is  larger,  and  occupies  more  space  than  when  in  the  fluid 
state,,  consequently  the  vessel  is  completely  closed.  If  MonsePs 
salt  cannot  be  obtained,  the  muriated  tincture  or  the  solution  of  the 
perchloride  of  iron  may  be  substituted,  which  can  always  be  found 
in  any  drug  store  even  in  the  interior  of  this  State.  The  prepara- 
tions of  iron  are  superior  to  other  haemostatics,  because  they  coagu- 
late the  blood  in  the  vessel,  which  renders  them  more  safe  and 
reliable  than  any  of  the  other  agents  of  this  character.  I  think  the 


156  LECTURES  ON  PRACTICAL  SURGERY. 

discovery  of  Monsel's  salt  was  one  of  the  most  useful  that  has  been 
made  in  surgery,  except  chloroform  and  the  silver  suture,  during 
the  last  half  century.  I  removed  the  tonsils  of  the  public  admin- 
istrator of  this  city  soon  after  it  was  discovered,  and  in  forty-eight 
hours  found  him  completely  exhausted  from  loss  of  blood.  He  had 
been  bleeding  four  or  five  hours,  and  I  was  apprehensive  that  it 
might  become  necessary  to  ligate  the  carotid  artery.  Lint  covered 
with  Monsel's  salt  was  applied  and  held  in  contact  with  the  wound 
for  five  minutes,  which  arrested  the  haemorrhage.  Should  the  blood 
escape  from  a  wound  produced  by  removing  the  right  tonsil  a  strip 
of  wet  lint,  one  inch  wide  and  three  inches  long,  should  be  placed 
upon  the  right  forefinger,  and  the  portion  upon  the  extremity  of  the 
finger  should  be  covered  with  Monsel's  salt  and  then  placed  upon 
the  bleeding  surface,  and  held  in  contact  with  it  for  five  minutes ; 
when  removed,  should  the  haemorrhage  return,  a  similar  application 
should  be  made  and  repeated  if  necessary.  Recently  I  removed 
the  tonsils  of  a  girl  about  ten  years  old,  and  on  the  evening  of  the 
second  day  the  wound  on  the  left  side  bled  so  rapidly  that  the 
parents  were  greatly  alarmed ;  Monsel's  salt  was  applied  without 
difficulty,  and  the  bleeding  vessels  were  closed  by  a  single  applica- 
tion. In  both  the  cases  mentioned  the  haemorrhage  did  not  occur 
until  the  second  day,  and  not  until  the  vessels  became  distended  by 
the  inflammation  that  succeeded  and  resulted  from  the  operation. 
The  haemostatic  now  under  consideration  is  inadmissible  whenever 
we  want  to  heal  a  wound  by  the  first  intention,  consequently  in  our 
plastic  operations  it  should  never  be  employed ;  but  in  such  cases, 
should  pressure  and  torsion  fail,  the  ligature  should  be  preferred. 
The  next  and  most  reliable  method  to  arrest  haemorrhage  is  by  the 
ligature.  You  have  all  seen  it  applied  in  the  City  Hospital,  and 
consequently  it  is  unnecessary  to  describe  the  operation  minutely. 
Ambrose  Pare",  one  of  the  most  distinguished  surgeons  of  his  day, 
was  the  first  to  apply  a  ligature,  about  the  end  of  the  sixteenth  cen- 
tury. Everything,  when  well  understood,  appears  simple,  and  you 
are  all,  no  doubt,  astonished  that  some  one  had  not  thought  of  it 
sooner.  Before  his  day,  when  an  artery  as  large  as  the  radial  or 
ulnar  was  wounded,  the  haemorrhage  almost  always  proved  fatal. 

Pare  in  applying  the  ligature  used  a  large  curved  needle,  and  in- 
cluded within  the  grasp  of  the  ligature  as  large  a  quantity  as  possi- 
ble of  the  surrounding  tissues. 


LECTURE    XII.  —  LIGATION    OF    ARTERIES.  157 

I  was  compelled  on  one  occasion,  and  when  I  was  very  young,  to 
adopt  that  method  in  the  following  case :  Mr.  Stockton,  who  still 
lives  in  Statesville,  North  Carolina,  was  thrown  from  a  buggy,  and 
had  a  compound  dislocation  of  the  ankle-joint.  His  physicians 
being  unable  to  agree,  I  was  called  from  an  adjoining  State  to  decide 
upon  the  course  that  should  be  pursued.  I  found  the  entire  tibia, 
except  about  three  inches  of  the  superior  extremity,  denuded,  and 
all  the  bones  of  the  ankle-joint  carious.  The  subcutaneous  cellular 
tissue  was  extensively  infiltrated  with  serum  and  imperfectly  organ- 
ized lymph.  As  it  was  impossible  to  save  the  limb,  and  three  or 
four  inches  of  the  tibia  being  healthy,  I  determined  to  operate  so  as 
to  save  the  knee-joint.  When  the  ligature  was  applied  to  the  artery, 
it  yielded  as  readily  and  made  as  little  resistance  as  could  be  expected 
from  an  ordinary  tallow  candle.  The  bones  were  then  removed  about 
an  inch  above.  The  ligature  was  then  made  to  include  a  considerable 
quantity  of  the  surrounding  cellular  tissue,  and  although  the  coats 
of  the  artery  were  diseased,  the  haemorrhage  was  thus  arrested,  the 
knee-joint  saved,  and  the  patient  not  only  made  a  rapid  recovery 
but  is  still  in  good  health. 

Bloomfield,  in  1772,  only  a  century  ago,  was  the  first  to  apply  a 
ligature  directly  upon  the  artery  without  the  intervention  of  the 
surrounding  parts.  It  was  drawn  out  with  a  tenaculum,  the  same 
instrument  that  is  now  used  for  that  purpose,  so  as  to  place  the  liga- 
ture as  far  above  the  open  mouth  of  the  vessel  as  possible,  which 
lessens  the  danger  of  secondary  haemorrhage.  Ordinarily  the  duck- 
billed forceps  are  used,  and  generally  they  are  preferable,  particu- 
larly in  deep  narrow  wounds.  Yet  a  difficult  and  extensive  opera- 
tion should  never  be  performed  without  having  within  reach  two  or 
three  pairs  of  spring  artery  forceps.  With  them  the  haemorrhage 
can  be  arrested  until  the  operation  is  either  completed  or  sufficiently 
advanced  to  ligate  them  properly. 

The  best  material  for  ligatures  is  silk,  and  the  size  should  depend 
upon  the  magnitude  of  the  vessel.  Every  bleeding  vessel  which 
does  not  yield  readily  either  to  pressure  or  torsion  should  be  ligated, 
in  order  to  avoid  secondary  haemorrhage,  which  may  come  on  in  a 
few  hours,  or  even  in  much  less  than  an  hour  after  the  wound  has 
been  dressed.  When  the  artery  is  large,  I  always  use  a  flat  ligature 
composed  of  four  threads  of  saddlers'  or  sewing  machine  silk,  and 
apply  it  firmly,  and  I  have  never  been  troubled  with  secondary 


158  LECTURES    ON    PRACTICAL    SURGERY. 

haemorrhage  except  in  one  case,  and  that  occurred  after  ligating  the 
external  iliac,  in  consequence  of  the  existence  of  a  hsemorrhagic  ten- 
dency, as  the  blood  escaped  not  from  the  iliac  artery,  but  from  the 
vessels  wounded  when  the  peritoneum  was  detached  from  the  iliac 
fossa.  The  vessels  were  so  small  that  not  an  ounce  of  blood  escaped 
during  the  operation,  but  on  the  third  day  the  loss  of  blood  was 
sufficiently  profuse  to  destroy  the  life  of  a  patient  already  exhausted 
by  a  previous  haemorrhage.  Against  that  peculiar  constitutional 
tendency  a  surgeon  cannot  guard,  but  in  no  other  cases  in  which  it 
has  become  necessary  in  my  practice  to  ligate  the  large  vessels  have 
I  ever  been  troubled  with  secondary  haemorrhage,  satisfied  that  the 
use  of  two  flat  ligatures,  and  the  force  used  in  the  application,  which 
is  nearly  as  much  as  I  can  exert,  is  the  only  reason  that  can  be  as- 
signed for  the  exemption,  except  it  be  that  I  never  employ  the  sur- 
geon's knot  in  such  cases,  and  always  apply  two  ligatures,  one  at 
each  end  of  the  opening  in  the  sheath.  I  confine  the  surgeon's  knot 
to  silk  sutures  used  for  closing  external  wounds.  If  an  artery  be 
wounded  both  ends  should  be  tied ;  never,  if  it  be  possible  to  expose 
the  vessel  at  the  point  injured,  apply  the  ligature  above.  The  ex- 
ternal wound  should  be  enlarged  sufficiently  to  enable  you  to  secure 
the  vessel  promptly.  The  same  course  should  be  pursued  when  a 
vessel  has  been  divided  without  an  extensive  external  wound.  Leech- 
bites  frequently  bleed  very  obstinately,  so  much  so  in  some  cases  as 
to  prove  fatal.  Should  the  application  of  dry  lint  combined  with 
pressure  or  the  haemostatics  previously  recommended  fail,  then  a 
small  pin  should  be  passed  through  the  lips  of  the  wound  and  se- 
cured by  the  figure-of-8  suture.  This  cannot  fail  even  when  the 
haemorrhagic  tendency  is  decided.  When  blood  escapes  from  the 
umbilicus  a  few  days  after  birth,  the  haemorrhage  is  always  exceed- 
ingly obstinate  and  sometimes  fatal.  In  the  cases  with  which  I 
have  met,  jaundice  existed,  produced  by  enlargement  and  induration 
of  the  liver.  Recently,  in  a  case  which  occurred  in  this  city,  the 
flow  of  blood  was  arrested  by  passing  two  large  flexible  pins  through 
the  umbilicus  as  near  the  abdomen  as  possible ;  at  right  angles  above 
these  a  strong  flat  ligature  was  applied  with  sufficient  force  to  con- 
trol the  circulation.  It  was  allowed  to  remain  six  days,  and  until 
the  hepatic  derangement  was  removed  by  the  use  of  the  proper  rem- 
edies. 

Whenever  an  artery  is  accessible,  no  matter  how  small,  it  is  always 


LECTURE    XII.  —  VENOUS    HAEMORRHAGE.  159 

more  safe  to  apply  a  ligature.  You  can  sleep  more  comfortably 
after  performing  an  extensive  and  dangerous  operation,  when  you 
know  that  the  vessels  have  all  been  ligated,  and  that  the  wound  was 
not  dressed  until  reaction  was  fully  established,  and  that  a  coagulum 
had  formed  in  those  too  small  to  require  a  ligature.  When  a  vein 
is  wounded  it  may  be  the  source  of  a  troublesome  haemorrhage, 
although  a  different  course  of  treatment  is  required.  In  such  cases 
you  should  neither  apply  haemostatics  nor  the  ligature,  but  rely  en- 
tirely on  pressure ;  your  object  should  be  to  arrest  the  flow  of  blood, 
and  effect  union  by  the  first  intention.  Such  wounds  when  properly 
treated  are  not  as  dangerous  as  many  surgeons  suppose.  The  internal 
jugular  vein  is  sometimes  so  large  as  to  conceal  the  carotid  artery;  and 
may  be  wounded  in  endeavoring  to  expose  that  vessel;  this  oc- 
curred in  a  case  in  which  I  ligated  the  artery  before  removing  a 
tumor  from  the  mouth.  The  artery  not  being  sufficiently  exposed, 
the  external  wound  was  enlarged  with  blunt  scissors,  and  the  in- 
ternal jugular  wounded ;  a  small  portion  of  clean,  soft  sponge  was 
applied,  and  retained  by  the  finger  of  an  assistant  until  the  operation 
was  completed.  A  single  point  of  the  interrupted  suture  was  then 
substituted,  and  on  the  tenth  day  the  sponge,  being  detached  by  sup- 
puration, was  removed,  and  the  patient  experienced  no  inconvenience 
from  the  accident.  The  same  course  was  pursued  successfully  in  a 
case  of  profuse  haemorrhage  from  the  haemorrhoidal  veins.  In  that 
case  the  sponge  was  introduced,  and  kept  in  contact  with  the  wounded 
veins  until  it  adhered  firmly  to  the  surface,  and  was  left  in  that  posi- 
tion by  keeping  the  bowels  constipated  for  five  days,  and  when  re- 
moved there  was  no  return  of  the  difficulty.  I  treated  a  case  in  this 
city  in  which  the  femoral  vein  was  wounded,  during  an  operation 
for  caries  of  the  femur,  with  the  same  result.  Some  years  since,  a 
butcher  at  the  corner  of  Second  and  Stevenson  Streets,  wounded  the 
external  iliac  vein ;  the  case  was  treated  successfully  by  Dr.  Carman 
and  myself  by  applying  a  firm  compress,  and  securing  it  by  a  roller 
bandage.  I  have  never  lost  a  patient  by  venous  haemorrhage  which 
resulted  from  a  wound.  It  is  easily  arrested  by  pressure,  and  the 
wound  in  the  vessel  heals  by  the  first  intention.  When  secondary 
haemorrhage  occurs  after  an  operation,  what  course  should  be 
adopted  ?  The  dressings  should  be  removed  as  speedily  as  possible, 
the  wound  exposed,  cold  water  applied,  and  pressure  made  if  the 
escape  of  blood  be  sufficient  in  quantity  to  excite  alarm.  Some 


160  LECTURES    ON    PRACTICAL    SURGERY. 

years  ago  I  found  it  necessary,  in  consequence  of  the  existence  of 
gangrene  from  exposure  to  cold,  to  amputate  both  legs  below  the 
knees.  A  few  days  after  the  last  operation  a  messenger  came  to  my 
office  to  say  that  the  patient  was  bleeding  to  death.  Being  about  one 
hundred  yards  distant,  only  a  few  minutes  elapsed  before  I  saw  him. 
The  blood  was  running  in  a  full  stream  from  the  end  of  the  stump. 
The  bandages  were  removed  as  speedily  as  possible,  and  before  the 
stump  was  sufficiently  cleansed  to  enable  me  to  see  a  bleeding  vessel 
the  blood  ceased  to  flow.  It  appeared  to  ooze  from  the  surface  of  the 
entire  stump,  and  if  it  had  not  been  exposed,  and  cold  water  applied, 
it  would  most  probably  have  proved  fatal.  The  wound  was  not 
dressed  for  three  or  four  days,  and  then  it  presented  a  uniform 
granulating  surface.  Haemorrhage  of  this  character  is  frequently 
produced  by  bandaging  the  limb  too  tightly.  Indeed,  almost  all  the 
unfavorable  symptoms,  both  from  fractures  and  amputation,  result 
from  that  source.  If  in  such  cases  the  pressure  be  sufficient  to  produce 
pain,  and  it  is  long-continued,  inflammation  with  all  its  consequences 
is  inevitable.  This  is  a  subject  which  should  be  well  understood,  for 
nothing  is  so  important  in  surgery  as  the  ability  to  arrest  external 
haemorrhage  under  any  circumstances,  and  certainly  nothing  is  so 
alarming,  both  to  the  patient  and  friends,  yet  with  the  necessary  self- 
possession  it  is  not  difficult.  You  can  by  pressure  check  the  flow  of 
blood  even  from  the  femoral  artery  until  a  ligature  can  be  applied, 
and  the  difficulty  permanently  controlled. 


LECTURE    XIII. —  ANEURISM.  161 


'*•'***.*?* 

tfc» 


-W4  y  ° 

LECTURE   XIII. 

AN  aneurism  is  a  sac  which  contains  either  fluid  or  coagulated 
blood,  or  both,  and  communicates  with  an  artery.  When  the  coats  of 
an  artery  become  diseased,  as  explained  in  my  last  lecture,  aneurism 
may  occur.  It  may  result  from  either  a  pultaceous  or  atheromatous 
condition  of  the  inner  coats,  or  from  fatty  degeneration,  in  conse- 
quence of  which  the  walls  are  rendered  less  firm  and  resisting,  so 
that  the  vessel  at  that  point  enlarges,  and  an  aneurismal  tumor  is 
the  result.  This  description  is  applicable,  as  will  be  hereafter  ex- 
plained, to  true  aneurism.  The  internal  and  middle  coats  yield  more 
readily  than  the  external,  and  the  magnitude  the  tumor  may  acquire 
will  depend  upon  the  size  of  the  artery,  the  power  of  the  heart,  and 
the  location  of  the  tumor. 

Aneurisms  are  divided  into  true  and  false.  In  true  aneurism  one 
or  more  of  the  coats  of  the  vessel  remain  entire.  In  false  they  have 
all  yielded,  and  the  sac  is  formed  by  the  surrounding  tissues.  Such 
a  condition  may  be  produced  either  by  the  rupture  of  a  true  aneu- 
rismal sac,  or  by  an  incised,  punctured,  or  contused  wound.  It  is,  how- 
ever, usually  due  to  wounds  made  by  small  cutting  instruments, 
which  divide  the  coats  of  the  artery  without  inflicting  an  external 
wound  large  enough  to  give  rise  to  a  fatal  haemorrhage. 

True  aneurism  is  subdivided  into:  1st.  Fusiform;  2d.  Sacculated; 
3d.  Dissecting. 

1.  In  the  first  the  coats  of  the  artery  do  not  yield,  but  are  distended 
and  thickened.     This  occurs  generally  in  the  aorta,  and  is  not  unlike 
a  varicose  vein  which  is  enlarged,  thickened,  and  elongated.     It  is 
really  a  dilatation  of  all  the  coats  of  the  artery,  and  may  result  from 
hypertrophy  of  the  heart,  without  the  previous  existence  of  disease 
of  the  arteries. 

2.  The  most  common  form  is  the  sacculated,  which  is  the  term 
applied  to  the  variety  in  which  the  inner  coats  of  the  artery  on  one 
side  only  have  yielded.     If  atheromatous  or  fatty  degeneration  has 
been  confined  to  one  side,  or  has  progressed  more  rapidly  upon  one 
side  than  the  other,  the  part  in  which  it  has  made  the  greatest  prog- 

11 


162 


LECTURES  ON  PRACTICAL  SURGERY. 


ress  will  be  the  first  to  yield,  and  consequently  the  tumor  will  form 
at  that  point. 

3.  The  third  variety  is  called  the  dissecting.  In  this  form,  the 
blood,  after  passing  through  the  internal  and  middle  coats,  may  meet 
with  so  much  resistance  from  the  external,  that  it  will  make  its  way 
some  distance  between  them,  thereby  forming  a  second  vessel,  and 
finally  may  either  pass  into  the  artery,  from  four  to  six  inches  from 
the  point  at  which  it  escaped,  or  find  its  way  through  the  external 
coat  and  prove  speedily  fatal. 

It  is  believed  by  pathologists  that  fusiform  aneurism,  or  that  re- 
sulting from  simple  dilatation,  is  confined  exclusively  to  the  arteries 
of  the  brain  and  the  aorta.  Fig.  48  illustrates  a  case  of  sacculated 


FIG.  48. 


aneurism,  which  arises  entirely  from  the  side  of  the  vessel.  The 
tumor  is  composed  of  strata  or  different  layers  of  coagulated  blood, 
which  differ  in  color  in  proportion  to  the  time  they  have  occupied 


LECTURE    XIII. — ANEURISM.  163 

their  position.  The  external  present  a  whitish  appearance  ;  in  the 
middle  they  are  reddish,  but  red  blood  is  not  found  until  you  ap- 
proach the  centre  of  the  tumor.  I  recollect  that  some  years  ago  it 
became  necessary,  in  consequence  of  pressure  upon  the  trachea,  to 
remove  a  large  tumor  from  the  neck.  No  pulsation  could  be  detected, 
it  was  of  long  standing,  and  consequently  its  true  character  could 
not  be  ascertained.  An  incision  was  made  through  the  integuments 
and  subcutaneous  cellular  tissue,  and  the  tumor  exposed,  but  it  did 
not  present  the  appearance  of  an  ordinary  fibrous  tumor,  which 
was  supposed  to  be  its  character.  I  made  a  very  short  incision 
through  the  sac  and  into  the  cavity  of  the  tumor.  At  first  fibrin 
escaped,  then  coagulated  blood,  and  finally  a  current  of  arterial 
blood  as  large  as  the  carotid,  which  proved  that  it  was  an  aneurism 
in  which  the  pulsation  had  entirely  ceased.  Dr.  Wells,  of  Columbia, 
South  Carolina,  closed  the  opening  in  the  sac  with  his  forefinger  and 
thumb ;  the  external  wound  was  then  enlarged,  the  artery  soon  ex- 
posed both  above  and  below  the  tumor,  and  suitable  ligatures 
applied.  The  entire  sac  sloughed  away  in  four  or  five  days,  and  the 
patient  recovered.  » 

Fig.  49  represents  a  true  aneurism,  in  which  the  sac  has  yielded 
to  the  action  of  the  absorbents. 

The  arteries  most  liable  to  aneurism  are:  1.  The  aorta;  2.  The 
popliteal ;  3.  Femoral ;  4.  Axillary ;  5.  Carotid.  When  the  aorta 
becomes  greatly  enlarged,  the  sternum,  ribs,  vertebrae,  and  even  the 
clavicle  will  disappear,  and  indeed  any  bone,  no  matter  how  large 
or  solid  it  may  be,  will  yield  to  the  pressure  exerted  by  an  enlarged 
arterial  trunk.  Sometimes  these  tumors  acquire  an  extraordinary 
magnitude,  before  the  external  coat  with  the  surrounding  cellular 
tissue  and  integument  yield.  I  have  treated  six  cases  within  the 
last  two  years,  in  which  the  tumor  was  as  large  as  a  man's  fist  above 
the  level  of  the  ribs  and  sternum,  and  in  one  of  the  cases  both 
popliteal  arteries  were  similarly  affected.  He  died  at  sea  on  his  way 
to  the  East,  where  he  supposed  he  could  find  relief. 

Next  in  point  of  frequency  is  aneurism  of  the  popliteal  artery. 
I  have  ligated  the  femoral  more  frequently  than  any  other  vessel  for 
the  relief  of  that  difficulty.  Some  of  you  have  seen  two  aggravated 
cases  of  aneurism  of  the  femoral  artery  operated  upon  in  the  County 
Hospital.  The  external  iliac  was  ligated,  and  in  one  of  the  cases  the 
tumor  was  so  large  that  it  was  impossible  to  see  the  vessel.  The  en- 


164  LECTURES    ON    PRACTICAL    SURGERY. 

tire  sac  with  the  integument  sloughed,  and  still,  after  a  long  struggle, 
the  patient  recovered. 

Aneurism  of  the  carotid  artery  I  have  seldom  seen,  and  it  occurs 
much  less  frequently  there  than  in  the  axillary.  The  carotid  artery 
is,  however,  very  important  in  consequence  of  the  necessity  that  fre- 
quently exists  to  ligate  that  vessel  in  order  to  arrest  haemorrhage 
from  the  mouth  or  throat,  or  to  remove  an  enlarged  parotid  gland 

FIG.  49. 


or  other  tumors  from  the  neck  or  head.  Males  are  more  liable  to 
aneurism  than  females  because  they  are  required  to  make  more  vio- 
lent muscular  efforts.  Sailors  are  particularly  liable  to  popliteal 
Aneurism ;  I  have  met  with  more  than  double  as  many  cases  of  that 
character  as  of  any  other  variety  whilst  I  had  charge  of  the  United 
States  Marine  Hospital  in  this  city. 

False  aneurism  may  be  either  primary  or  secondary,  and  either 
circumscribed  or  diffused.  The  first  results  from  the  wound  of  an 
artery,  the  second  from  the  rupture  of  a  true  aneurismal  sac. 

In  one  case  upon  which  I  operated,  of  primary  false  aneurism,  the 


LECTURE    XIII.  —  SYMPTOMS    OF    ANEURISM  165 

brachial  artery  was  punctured  by  an  ordinary  duck-shot,  and  from 
this  was  developed  a  diffused  aneurism  that  extended  from  the  in- 
sertion of  the  biceps  above  that  of  the  deltoid.  The  sac  was  opened 
freely,  and  a  ligature  applied  both  above  and  below  the  wound,  and 
the  patient  made  a  rapid  recovery. 

Symptoms. — In  external  aneurism,  whether  true  or  false,  you  will 
always  find  a  tumor,  which  is  generally  either  oval  or  round  and 
circumscribed,  but  it  may  be  both  extensive  and  diffused.  Other 
tumors  may  present  the  same  shape  and  consistence,  and  the  only 
true  diagnostic  symptom  is  the  pulsation,  which  is  seldom  absent. 
Yet,  when  the  tumor  is  of  long  standing  and  the  cavity  is  filled 
with  coagulated  blood,  so  that  the  calibre  of  the  vessel  is  increased 
but  little  above  its  normal  condition,  the  pulsation  may  be  much  less 
distinct  than  in  recent  or  acute  cases,  or  may  disappear  altogether. 
It  generally  corresponds  with  the  pulsations  of  the  heart,  and  some- 
times if  the  ear  be  applied  to  the  tumor,  a  bruit  can  be  detected 
which  may  be  either  of  a  sawing  or  rasping  character,  and  is 
called  the  aneurismal  thrill ;  I  repeat  that  it  cannot  always  be  de- 
tected. 

You  should  be  exceedingly  cautious  in  giving  an  opinion  in  ref- 
erence to  the  existence  of  aneurism  of  the  abdominal  vessels.  Every 
day  errors  are  committed  by  physicians  who  mistake  abdominal 
tumors  of  a  different  character  for  aneurism,  and  even  the  pulsation 
of  the  abdominal  aorta,  which  is  sometimes  so  distressing  in  chronic 
irritation  of  the  stomach  and  bowels,  is  often  mistaken. for  the  same 
difficulty.  I  have  met  recently  with  three  cases  of  aneurism  of  the 
abdominal  aorta,  and  in  every  case  the  patient  was  unable  to  remain 
in  a  horizontal  position  without  suffering  the  most  intense  agony. 

In  aneurisms,  both  external  and  internal,  great  inconvenience 
must  necessarily  result  from  the  pressure  they  exert  upon  the  sur- 
rounding parts.  When  large  and  situated  in  the  popliteal  space, 
upon  the  upper  part  of  the  thigh,  or  in  the  axilla,  a  painful  oedema  of 
the  extremity  must  necessarily  exist.  When  located  in  the  chest  or 
abdomen,  the  functions  of  the  thoracic  and  abdominal  organs  will 
be  more  or  less  disturbed.  If  located  in  the  vicinity  of  a  nerve, 
which  is  generally  the  case,  not  only  excessive  pain  should  be  ex- 
pected, but  also  a  derangement  of  the  function  of  the  organ  which 
it  supplies.  A  tumor  of  this  character  should  be  expected  to  in- 
crease in  size  until  the  sac  is  either  ruptured  or  the  vessel  is  oblit- 


166  LECTURES    ON    PRACTICAL    SURGERY. 

erated  by  the  accumulation  of  laminated  fibrin  which  destroys  the 
circulation ;  the  fluid  contents  are  then  absorbed,  and  a  spontaneous 
cure  may  result. 

This  termination  is  unfortunately  very  rare,  yet,  improbable  as 
it  may  appear,  well-authenticated  cases  may  be  found  of  a  sponta- 
neous cure  having  occurred  in  aneurism  of  the  aorta.  Generally 
the  sac  yields  before  the  vessel  is  obliterated,  and  if  it  be  internal  a 
fatal  haemorrhage  must  result,  but  if  external  we  may  have  to  con- 
tend with  a  diffused  false  aneurism.  When  I  had  charge  of  the 
United  States  Marine  Hospital  of  this  city,  two  cases  of  that  char- 
acter were  admitted  within  a  few  weeks.  They  arrived  in  nearly 
the  same  condition.  About  six  weeks  after  leaving  New  York  for 
this  port,  they  were  compelled  to  make  violent  exertions,  and  soon 
afterwards  suffered  excruciating  pain  with  great  enlargement  of  the 
entire  foot  and  leg,  which,  with  the  confinement  and  want  of  care, 
deranged  the  general  health  so  much  that  they  appeared  to  be  almost 
in  a  hopeless  condition.  In  both  cases  the  fascia  of  the  leg  was 
distended  to  its  utmost  limit,  and  the  bones  were  both  denuded  to 
within  two  or  three  inches  of  the  knee-joint.  The  only  alternatives 
were  to  amputate  above  the  knee,  or  ligate  the  femoral  artery,  and 
when  the  soft  parts  sloughed  to  divide  the  bones  and  save  the  knee- 
joint.  The  femoral  artery  was  ligated  in  both  cases,  the  soft  parts 
sloughed  to  within  about  three  inches  of  the  knee,  the  bones  were 
divided,  and  the  knee-joint  with  a  portion  of  the  leg  saved.  In  one 
of  the  cases  the  entire  fibula  was  diseased,  but  a  sufficient  portion  of 
the  tibia  retained  its  vitality  to  make  a  good  stump.  They  both 
recovered  with  the  use  of  the  knee-joint,  which  is  very  important  to 
a  laboring  man.  In  such  cases,  instead  of  amputating  above  the 
knee,  always  ligate  the  femoral  artery,  and  when  the  soft  parts 
slough  divide  the  bones,  and  thus  save  as  much  of  the  leg  as  possible. 
In  some  cases  of  aneurism,  particularly  in  young  and  vigorous  sub- 
jects, the  sac  and  surrounding  tissues  frequently  inflame  and  even 
suppurate,  and  then  if  an  incision  is  not  made,  and  the  proper  means 
adopted  to  arrest  the  haemorrhage,  the  skin  will  ulcerate,  and  a  fatal 
termination  is  inevitable. 

The  question  now  arises,  how  should  aneurism  be  treated  in  order 
to  effect  a  radical  cure?  The  treatment,  as  in  almost  all  diseases,  is 
both  local  and  constitutional.  From  the  latter  no  very  decided  bene- 
ficial effect  can  be  expected  except  as  a  preparatory  measure.  Val- 


LECTURE   XIII. — TREATMENT    OF    ANEURISM.  167 

salva  recommended  bloodletting,  confinement  to  the  horizontal  pos- 
ture, and  almost  absolute  starvation,  his  patients  not  being  allowed 
more  than  six  ounces  of  solid  food  in  twenty-four  hours.  This 
treatment,  if  ever  useful,  could  only  have  an  injurious  effect  upon 
the  infirm,  whether  from  disease  or  old  age.  In  such  cases  tonics 
combined  with  iron  when  indicated  should  be  administered,  and 
every  means  adopted  to  improve  the  general  health  before  resorting 
to  the  local  treatment,  which  will  be  hereafter  specified.  When  the 
patient  is  vigorous,  and  the  tumor  is  either  enlarging  rapidly  or  is 
painful,  rest,  low  diet,  and  an  occasional  cathartic  should  be  pre- 
scribed ;  to  control  increased  arterial  action  the  depressant  mixture, 
previously  recommended,  should  be  administered  and  continued 
until  the  pulse  is  reduced  to  its  natural  and  healthy  standard ;  this 
is  greatly  preferable  to  repeated  abstractions  of  blood  under  any 
circumstances.  I  have  pursued  this  course  of  treatment  for  months 
in  cases  of  internal  aneurism,  with  the  effect  probably  of  protracting 
a  life  of  pain  and  anxiety,  without  ever  having  witnessed  any  per- 
manent good  effect,  and  I  now  only  prescribe  it  to  prepare  a  patient 
for  local  treatment,  which  is  very  important,  and  contributes  greatly 
to  the  success  of  these  remedies. 

Before  the  time  of  John  Hunter  the  treatment  of  aneurism  con- 
sisted in  opening  the  sac,  removing  the  contents,  and  arresting  the 
haemorrhage  by  the  use  of  the  actual  cautery ;  this  generally  failed, 
and  amputation  frequently  became  necessary.  To  John  Hunter, 
who  was  the  medical  genius  of  his  time,  is  due  the  credit  of  having 
first  applied  a  ligature  above  the  tumor  to  effect  a  radical  cure, 
although  but  few  of  his  patients  recovered,  in  consequence  of  the 
imperfect  manner  in  which  the  operation  was  performed.  The 
ligature  was  not  applied  sufficiently  tight  to  divide  the  middle  coat 
of  the  artery,  consequently  the  inflammation  that  resulted  was  not 
sufficient  to  supply  the  necessary  deposition  of  plastic  lymph  to 
obliterate  the  vessel. 

For  the  present  improved  method  of  treating  aneurism  we  are  in- 
debted to  Hodgson,  Lawrence,  Travers,  Cooper,  Abernethy,  Post, 
and  Mott.  They  applied  the  ligature  firmly  and  were  often  success- 
ful. The  ligature  should  be  large,  flat,  and  applied  with  sufficient 
force  to  divide  the  middle  coat  of  the  artery.  Of  all  the  ligatures 
which  I  have  applied  in  such  cases  only  one  failed  to  obliterate  the 
vessel,  and  that  was  in  the  case  already  mentioned  in  which  there 


168  LECTURES    ON    PRACTICAL    SURGERY. 

existed  a  hsemorrhagic  tendency,  and  was  first  applied  upon  the 
femoral  near  Poupart's  ligament.  The  ligation  of  that  vessel,  in  the 
exhausted  condition  of  the  patient  from  haemorrhage,  which  resulted 
from  a  wound  of  the  profunda  femoris,  offered  the  most  favorable 
prospect  of  success.  Secondary  haemorrhage  occurred  on  the  ninth 
day,  when  the  external  iliac  was  ligated,  the  condition  of  the  pa- 
tient having  been  greatly  improved  by  proper  treatment;  but  in 
three  days  he  bled  to  death  from  the  small  vessels  ruptured  in  de- 
taching the  peritoneum  from  the  iliac  fossa.  It  is  not  very  difficult 
to  tie  an  artery,  but  after  the  circulation  in  one  is  destroyed  by  a 
ligature,  the  parts  which  the  vessel  supplies  may  lose  their  vitality, 
and  most  assuredly  will  if  proper  treatment  is  not  adopted.  Some 
years  since,  after  ligating  a  large  artery  for  aneurism,  I  applied  hot 
sand-bags,  but  from  the  difficulty  experienced  in  keeping  these  at  a 
proper  temperature,  I  now  envelop  the  lirnb  with  flannel,  cover  it 
with  oiled  silk,  and  then,  until  it  is  certain  that  the  circulation 
has  been  re-established  by  the  collateral  branches,  the  extremity 
should  be  surrounded  by  bottles  filled  with  warm  water;  when 
proper  precautions  are  taken  they  are  preferable  to  heated  sand, 
bricks,  or  indeed  any  other  application  that  can  be  made.  They 
should  only  be  employed  until  the  natural  temperature  of  the  part 
has  been  restored,  but  the  use  of  the  flannel  and  oiled  silk  should 
be  kept  up  until  the  patient  has  recovered  sufficiently  to  use  the 
limb,  when  a  common  roller  bandage  should  be  substituted.  You 
must  not  suppose  that  when  you  have  Jigated  an  artery,  applied 
flannel  and  oiled  silk  as  I  have  recommended,  and  administered 
opium  enough  to  relieve  pain,  the  patient  is  safe,  and  that  no  other 
difficulty  can  occur  by  which  the  recovery  may  either  be  prevented 
or  retarded.  You  all  witnessed  the  ligation  of  the  femoral  artery  a 
few  days  since  in  the  hospital,  for  popliteal  aneurism.  The  case  was 
acute,  compression  could  not  be  borne,  the  man's  general  health  was 
greatly  impaired,  yet  it  was  necessary  to  ligate  the  vessel.  The  vessel 
was  easily  exposed  and  tied,  and  the  symptoms  were  favorable  for  eight 
or  ten  days ;  he  then  became  restless,  with  a  small  quick  pulse  and 
the  other  constitutional  symptoms  of  approaching  dissolution,  and 
upon  examining  the  limb  to  ascertain  the  cause  it  was  found  to  be 
mortified  even  above  the  ligature.  A  post-mortem  examination  was 
made,  and  it  was  ascertained  that  the  artery  was  obliterated  by  a  firm 
coagulum  of  more  than  an  inch  in  length  above  the  point  to  which 


LECTURE    XIII. — TREATMENT    OF    ANEURISM.  169 

the  ligature  was  applied.  The  internal  coat  of  all  the  large  arteries 
was  diseased  and  softened.  This  was  the  only  case  in  which  I  have 
ever  performed  an  operation  for  aneurism  in  which  mortification 
occurred.  Although  it  is  not  frequent,  yet  when  it  does  take  place  it 
is  always  unfortunate;  it  is  more  liable  to  occur  when  the  patient  is 
feeble  and  exhausted,  either  by  age,  disease,  or  haemorrhage. 

When  the  ligature  is  detached,  even  if  properly  applied,  should 
the  vessel  be  diseased,  secondary  haemorrhage  may  follow,  and  if  it 
does  it  is  almost  always  fatal.  In  such  cases,  when  practicable,  it  is 
always  better  to  amputate  the  limb  than  to  apply  a  ligature  above, 
because  gangrene  often  follows  the  application  of  a  second  ligature, 
and  the  patient  may  survive  the  loss  of  an  extremity.  You  have 
also  had  an  opportunity  of  watching  the  progress  of  the  suppura- 
tion and  sloughing  of  an  aneurismal  sac  of  enormous  dimensions, 
which  followed  the  ligation  of  the  internal  iliac  artery.  Five  or  six 
days  after  the  operation  was  performed  the  man  complained  of  pain 
in  the  tumor,  which  without  any  pulsation  increased  in  size  steadily 
until  the  fifteenth  day,  when  I  observed  that  the  skin  was  disposed 
to  slough.  A  free  incision  was  then  made,  and  two  or  three  quarts  of 
dark  offensive  coagulated  blood  mixed  with  unhealthy  purulent  matter 
escaped.  I  removed  with  my  hands  all  that  could  be  conveniently 
detached ;  the  sac  was  kept  filled  with  a  solution  of  the  chlorate  of 
potassium,  5v  to  the  quart  of  water;  the  same  solution  was  applied 
externally,  and  evaporation  prevented  by  oiled  silk.  Twelve  ounces 
of  good  sherry  wine  with  twelve  grains  of  stilph.  quinise,  and  as 
much  nutritious  food  as  he  could  digest,  were  given  every  twenty- 
four  hours,  and,  gentlemen,  I  need  not  say  to  you  that  he  made  a 
miraculous  recovery.  He  is  now  well,  and  beyond  a  contingency. 
The  removal  of  the  contents  of  the  sac  was  not  followed  by  much 
haemorrhage,  which  under  the  circumstances  must  have  proved  fatal 
in  consequence  of  the  exhausted  condition  of  the  patient.  When  it 
is  impossible  to  apply  a  ligature  between  the  centre  of  circulation 
and  the  tumor,  or  on  its  proximal  side,  then  Brasdor's  method  may 
be  substituted  with  in  many  cases  a  fair  prospect  of  success.  He 
applied  the  ligature  beyond  or  upon  the  distal  side  of  the  tumor.  The 
object  of  this  operation  is  the  same  as  that  of  the  Hunterian.  It  either 
arrests  or  lessens  the  flow  of  blood  through  the  tumor,  and  favors  the 
deposition  ot  laminated  fibrin  by  which  the  artery  is  both  filled  and 
obliterated.  I  have  never  performed  this  operation  but  once,  and, 


170          LECTURES  ON  PRACTICAL  SURGERY. 

then  with  the  most  satisfactory  result.  The  patient  had  disease  of 
the  heart  as  well  as  aneurism  of  the  axillary  artery ;  the  existence  of 
the  former  rendered  it  improper  to  ligate  the  subclavian,  and  the  sac 
being  very  thin  and  inflamed,  I  determined  to  give  him  the  chance 
which  Brasdor's  operation  afforded.  The  brachial  artery  was  ligated 
about  two  inches  below  the  sac;  the  pulsation  in  the  tumor  gradu- 
ally diminished,  and  by  the  fifth  day  ceased  entirely.  When  I  lost 
sight  of  him  three  or  four  weeks  after  the  operation,  the  tumor  was 
reduced  to  half  its  original  size,  was  firm  and  had  ceased  to  pulsate. 
This  case  was  published  in  the  Pacific  Medical  Journal,  with  the 
necessary  details  to  substantiate  the  correctness  of  the  statement  made 
above. 

Sometimes  in  a  few  days  after  the  application  of  a  ligature,  when 
pulsation  has  ceased  entirely,  it  returns,  and  may  continue  for  a  short 
period,  and  then  disappear.  This  is  considered  much  more  favora- 
ble than  for  it  to  return  in  a  month  or  six  weeks  after  the  operation. 
It  then  depends  on  the  collateral  branches  communicating  with  the 
tumor,  and  if  it  should  not  disappear  it  can  be  removed  by  rest,  and 
the  application  of  a  bandage.  I  have  performed  more  operations 
for  aneurism  than  any  surgeon  in  America,  yet  I  have  never  after 
the  ligature  was  tightened,  except  by  Brasdor's  method,  been  able  to 
detect  the  slightest  pulsation. 

Treatment. — Compression,  when  the  heart  is  diseased  or  the  aneu- 
rismal  tumor  has  increased  rapidly,  and  particularly  when  the  cir- 
cumstances of  the  patient  will  enable  him  to  obtain  the  necessary 
attention,  should  be  tried  before  the  application  of  a  ligature  is 
recommended.  Compression  has  been  applied  directly  upon  the 
tumor,  and  sometimes  a  favorable  result  has  been  obtained.  It  is 
much  better,  however,  to  make  the  pressure  above,  and  the  best  in- 
struments are  Carte's  or  Signoroni's  horseshoe  tourniquet  (Fig.  50). 
As  this  plan  is  only  applicable  to  aneurism  of  the  arteries  of  the 
lower  extremities,  and  particularly  of  the  popliteal,  much  depends 
upon  the  manner  in  which  compression  is  made,  and  more  upon  the 
attention  given  to  the  minute  details  in  the  treatment  of  a  case  than 
upon  the  method  adopted.  After  the  limb  has  been  shaved,  pow- 
dered, and  bandaged,  a  tourniquet  should  be  applied,  both  at  the  groin 
and  lower  down  upon  the  thigh,  so  that  when  the  pressure  becomes 
painful  at  one  point  the  instrument  can  be  relaxed,  and  sufficient 
pressure  made  with  the  other  to  retard  but  not  to  arrest  the  circula- 


LECTURE    XIII.  —  TREATMENT    OF    ANEURISM. 


171 


tion  entirely.  It  should  diminish  the  volume,  and  retard  the  ve- 
locity of  the  blood  so  much  as  to  favor  the  deposition  of  laminated 
fibrin,  by  which  the  vessel  may  be  ultimately  obliterated,  and  a 
radical  cure  effected.  Sometimes  under  this  method  the  pulsation 
in  the  tumor  will  cease  in  a  few  days,  but  in  other  cases  it  becomes 
necessary  to  continue  the  treatment  at  least  three  months  before  it 
entirely  disappears.  Under  all  circumstances  the  pressure  should  be 


FIG.  50. 


continued  at  least  forty -eight  hours  after  the  circulation  in  the  vessel 
has  entirely  ceased,  in  order  to  prevent  a  recurrence  of  the  difficulty. 
As  compression  is  usually  less  dangerous  than  the  application  of  a 
ligature,  and  since  every  patient  with  popliteal  aneurism  requires 
preparatory  treatment,  I  think  the  method  by  compression  should 
be  tried,  and  should  that  fail  a  ligature  maybe  applied,  with  as  good 
a  prospect  of  success  as  if  the  patient  had  not  been  subjected  to  any 
other  method  of  treatment.  Fergusson  has  proposed  to  treat  some 
cases  of  aneurism  by  what  he  calls  manipulation,  which  consists  in 
making  pressure  upon  the  tumor  in  such  a  manner  as  to  displace  a 


172  LECTURES    ON    PRACTICAL    SURGERY. 

portion  of  the  coagulum,  and  thereby  obstruct  the  distal  extremity 
of  the  vessel.  A  rupture  of  the  sac  is  the  only  danger  to  be  appre- 
hended from  such  treatment.  In  hopeless  casas,  or  those  in  which 
neither  compression  nor  the  ligature  are  admissible,  this  method 
might  be  employed.  Petrequin  and  Burci  have  both  recommended 
and  practiced  galvano-puncture,  which  consists  in  passing  two  acu- 
puncture needles  into  the  sac  in  opposite  directions,  but  so  as  to  re- 
main in  contact,  and  connected  with  a  galvanic  battery  of  moderate 
power,  the  action  of  which  is  supposed  to  favor  coagulation,  and  ulti- 
mately to  produce  the  effect  both  of  compression  and  the  ligature. 
The  result  has  not  been  sufficiently  satisfactory  to  encourage  others 
to  adopt  the  treatment,  since  the  inflammation  which  it  produces  has 
been  in  some  cases  so  violent  as  to  give  rise  to  sloughing  and  fatal 
hsemorrhage.  The  solution  of  the  perchloride  of  iron  has  been  in- 
jected into  the  sac,  for  the  purpose  of  coagulating  the  contents  and 
obliterating  the  vessel.  It  is  too  dangerous  and  uncertain  a  remedy 
to  be  employed.  I  have  treated  some  naevi  in  that  manner  success- 
fully, but  in  every  case  the  entire  tumor  sloughed,  which  would  be 
exceedingly  dangerous  in  a  case  of  aneurism. 

Before  closing  this  lecture  I  beg  leave  to  direct  your  attention  to 
dilatation  of  the  veins.  They  become  enlarged,  elongated,  and  thick- 
ened. The  spermatic  veins  and  those  of  the  lower  extremities  are 
most  liable  to  dilatation,  yet  it  may  occur  upon  almost  any  portion 
of  the  body. 

The  spermatic  vein  of  the  left  testicle  is  more  frequently  enlarged 
than  that  of  the  right,  because  it  is  longer,  enters  the  renal  at  right 
angles,  and  consequently  is  exposed  to  the  pressure  exerted  by  a  large 
column  of  blood,  and  being  destitute  of  valves  it  sometimes  becomes 
so  enormously  distended,  that  the  function  of  the  organ  is  impaired. 
Spermatorrhoea  almost  always  accompanies  this  difficulty,  and  unless 
the  cause  is  removed  cannot  be  cured. 

You  should  always  operate  in  such  cases.  Pressure  is  sufficient 
to  obliterate  the  vein.  The  constituents  of  the  cord,  and  particu- 
larly the  spermatic  duct,  should  be  separated  from  the  vein,  and  when 
this  is  isolated  two  large  pins  should  be  passed  behind  it,  the  first 
above  and  near  the  superior  extremity  of  the  testicle,  and  another 
about  an  inch  above.  A  figure-of-8  ligature  should  then  be  applied, 
the  extremities  of  the  pins  removed,  and  the  patient  required  to  re- 
main in  bed  from  five  to  seven  days,  according  to  the  degree  of  inflam- 


LECTURE    XIII. — VARICOCELE.  173 

raation  which  may  ensue.  When  considerable  it  may  be  necessary  to 
remove  the  pins  as  early  as  the  fifth  day,  or  they  sometimes  may  be 
allowed  to  remain  seven  or  eight  when  but  little  inconvenience 
results  from  their  presence. 

I  can  recommend  this  operation  as  being  entirely  safe,  and  it  rarely 
fails,  either  in  varicocele  or  varicose  enlargement  of  the  veins  of  the 
leg,  from  which  the  most  troublesome  ulcers  result.  The  vein  should 
be  raised  with  the  finger  and  thumb  of  the  left  hand,  the  pin  passed 
under  the  vein,  and  the  ligature  adjusted  so  as  to  check  the  circulation, 
but  not  sufficiently  tight  to  produce  ulceration  of  the  skin.  The  pins 
should  be  inserted  at  intervals  of  three  or  four  inches ;  if  blood  fol- 
lows the  introduction,  they  should  be  removed,  for  should  they  wound 
a  vein  and  be  allowed  to  remain,  phlebitis  would  certainly  follow. 


174 


LECTURES  ON  PRACTICAL  SURGERY. 


LECTURE   XIV. 

GENTLEMEN  :  The  hour  expired  before  all  the  varieties  of  aneu- 
rism were  considered ;  that  which  was  omitted  is  called  varicose. 
It  is  not  very  common,  although  it  was  described  by  John  Hunter 
as  early  as  1756,  and  it  reminds  me  of  a  remark  I  made  to  the  class 


FIG.  51. 


in  my  lecture  on  minor  surgery,  in  reference  to  venesection,  that  you 
should  never  open  a  vein  which  lies  directly  over  an  artery,  for  the 
lancet  may  pass  through  the  vein,  and  wound  the  deeper-seated 
vessel,  and  the  blood,  after  the  surrounding  cellular  tissue  becomes 
distended,  will  flow  from  the  artery  directly  into  the  vein,  which  will 


LECTURE    XIV.  —  OPERATIONS    FOR    ANEURISM.  175 

become  gradually  distended,  thus  explaining  the  origin  of  the  name 
varicose.  The  extremity  below  the  seat  of  the  injury  becomes  con- 
gested and  swollen,  so  that  it  is  necessary  to  apply  a  bandage,  until 
the  artery  can  be  ligated  both  above  and  below  the  wound,  provided 
this  be  practicable;  if  not,  a  ligature  should  be  applied  above 
and  pressure  made  over  the  tumor,  and  continued  until  the  pulsation 
ceases  and  the  enlargement  is  greatly  diminished. 

Having  described  both  the  varieties  and  treatment  of  aneurism, 
it  is  now  necessary  to  give  the  various  operations  which  you  may  be 
required  to  perform  in  order  to  effect  a  radical  cure.  The  femoral 
artery,  after  passing  about  one-third  the  distance  from  Poupart's 
ligament  to  the  knee,  occupies  the  triangular  space  formed  by  the 
sartorius  and  quadriceps  adductor  muscles.  By  flexing  the  knee,  and 
turning  the  thigh  outwards,  the  muscles  are  relaxed,  and  the  space 
rendered  very  distinct,  except  when  it  is  filled  and  obscured  by  an 
excess  of  adipose  tissue.  The  artery  may  be  tied  either  above  or  below 
the  sartorius,  and  but  little  difficulty  will  be  experienced  in  securing 
it  in  either  position  (Fig.  52).  An  incision  three  or  four  inches  long 
should  be  made,  either  with  a  scalpel  or  bistoury,  through  the  skin, 
cellular  tissue,  and  fascia,  and  then  the  vessel  can  be  exposed  by  a 
director  or  the  handle  of  a  scalpel,  without  either  difficulty  or  danger, 
as  was  demonstrated  in  the  operation  I  performed  yesterday,  before 
the  class,  for  popliteal  aneurism.  The  sheath  of  the  vessel  was  then 
opened  with  blunt-pointed  scissors,  and  the  aneurism-needle  passed 
under  the  artery.  When  no  doubt  existed  respecting  the  part  ex- 
posed, and  that  neither  the  vein  nor  nerve  was  included  in  the  grasp 
of  the  ligature,  the  needle  was  removed,  and  the  ligature  tightened 
with  a  simple  square  knot,  which  divides  the  coats  of  the  vessel  far 
more  effectually  and  certainly  than  would  have  been  possible  if  the 
surgeon's  knot  had  been  substituted.  The  ligature  should  be  at 
least  twelve  inches  long,  and  should  be  placed  and  retained  in  the 
lower  extremity  of  the  wound,  which  will  prevent  union  by  the  first 
intention,  and  remove  the  necessity  of  interposing  lint  between  the 
edges.  The  upper  portion  of  the  wound  should  then  be  united  by 
two  or  three  points  of  the  interrupted  silver  suture.  The  water- 
dressing  should  then  be  applied,  and  renewed  two  or  three  times  in 
twenty-four  hours,  or  more  frequently  should  the  purulent  discharge 
be  profuse.  That  patient  may  die  from  purulent  absorption,  second- 
ary haemorrhage,  ulceration,  or  mortification  of  either  the  sac  or  the 


176 


LECTURES    ON    PRACTICAL    SURGERY. 


entire  extremity,  consequently  all  the  means  recommended  should  be 
employed  to  prevent  the  casualties  above  enumerated.  The  entire 
extremity,  as  you  observed,  was  wrapped  in  flannel,  and  covered  with 
oiled  silk ;  half  a  grain  of  sulphate  of  morphia  was  then  administered 
to  relieve  pain.  The  limb  was  placed  upon  the  fibular  side,  and 
slightly  flexed.  The  ligature  usually  remains  on  the  vessel  about 
seventeen  days,  although  sometimes  longer,  and  may  require,  as 
recommended  by  Professor  Dudley,  a  large  bullet  to  be  attached  to 
its  outer  extremity,  which  by  its  weight  in  a  few  days  will  enable 
you  to  remove  it  without  difficulty.  I  have  never  found  it  necessary 


FIG.  52. 


to  resort  to  this  method,  having  always  succeeded  by  moderate  trac- 
tion in  removing  it  before  the  wound  cicatrized.  Should  the  opening 
in  the  sheath  of  the  vessels  be  half  an  inch  in  length,  then  two  lig- 
atures should  be  applied,  one  at  each  extremity.  I  have  always 
adopted  that  course  and  have  had  no  reason  to  complain  of  the  result. 
The  anterior  tibial  artery  sometimes  requires  a  ligature,  and  par- 
ticularly in  false  aneurism.  It  may  be  ligated  at  any  point,  from  the 
knee  to  the  instep.  Until  the  vessel  comes  within  four  inches  of  the 


LECTURE    XIV.  —  LIGATION  OF   ARTERIES.  177 

ankle-joint  it  is  found  upon  the  interosseous  membrane,  and  between 
the  tibialis  anticus  and  extensor  communis,  and  below  that  point, 
between  the  extensor  pollicis  longus  and  tibialis  anticus ;  for  two- 
thirds  of  its  course  it  is  deepseated,  and  in  consequence  of  the  den- 
sity of  the  fascia  it  is  exposed  with  great  difficulty.  Tlje  artery  is 
accompanied  by  two  veins,  which  should  be  avoided  ;  the  nerve,  from 
its  position,  is  not  likely  to  be  included  in  the  ligature.  A  tourni- 
quet should  always  be  applied  to  the  thigh ;  an  incision  is  made  three 
inches  long  and  about  three-quarters  of  an  inch  from  the  edge  of  the 
tibia;  the  fascia  is  divided,  and  the  intermuscular  space  should  be 
followed  until  the  artery  is  exposed.  Should  the  vessel  be  wounded, 
the  wound  should  be  enlarged  and  the  fascia  divided  transversely, 
so  as  to  expose  the  part  more  readily  than  would  be  possible  unless 
that  precaution  were  taken.  Upon  the  instep  the  artery  is  so  super- 
ficial, that  no  difficulty  will  be  experienced  either  in  exposing  the 
vessel  or  applying  a  ligature.  The  wound  should  be  closed  as  pre- 
viously directed,  and  the  same  course  pursued  both  in  the  local  and 
constitutional  treatment.  This  was  the  first  operation  I  ever  per- 
formed ;  it  was  done  at  night,  by  torchlight,  upon  a  man  who  had 
wounded  the  anterior  tibial  artery  the  day  previous.  The  wound 
was  enlarged,  the  fascia  and  muscles  were  divided  transversely,  and 
when  the  vessel  was  exposed,  it  was  raised  with  a  bent  probe,  and  a 
ligature  applied  both  above  and  below  the  wound.  Being  very 
young,  and  consequently  inexperienced,  with  a  poor  light  and  few 
instruments,  I  found  it  exceedingly  difficult.  Should  such  a  case  be 
met  with  now,  I  would  fill  the  wound  with  lint,  apply  a  bandage 
sufficiently  tight  to  arrest  the  haemorrhage,  and  defer  the  operation 
until  the  following  day.  It  sometimes  becomes  necessary  to  ligate 
this  vessel  to  arrest  the  haemorrhage  from  a  wound  of  the  foot,  or 
to  check  the  growth  of  a  vascular  tumor  which  is  supplied  by  its 
branches. 

Posterior  Tibial. — This  vessel  should  be  ligated  under  the  circum- 
stances already  mentioned,  and  if  it  be  possible  to  select  the  location, 
it  can  be  found  at  the  centre  of  a  line  extending  from  the  malleolus 
internus  to  the  insertion  of  the  tendo  Achillis.  It  can  generally  be 
both  seen  and  felt  at  that  point  very  distinctly,  and  to  expose  the 
vessel  it  is  only  necessary  to  divide  the  skin  and  fascia.  It  is  accom- 
panied by  two  veins,  and  the  posterior  tibial  nerve  is  located  between 
the  artery  and  the  os  calcis.  An  incision  two  inches  long  will  enable 

12 


178  LECTURES    ON    PRACTICAL    SURGERY. 

you  to  expose  the  vessel  and  apply  a  ligature.  Four  inches  above 
the  ankle  the  incision  should  be  three  inches  in  length,  and  half  an 
inch  posterior  to  the  margin  of  the  tibia ;  the  vessel  rests  upon  the 
flexor  communis  and  tibialis  posticus  muscles,  as  below  it  is  accompa- 
nied by  two  veins,  and  the  nerve  lies  between  it  and  the  fibula.  The 
posterior  tibial,  two  inches  higher  up,  being  covered  by  the  soleus 
muscle,  it  then  becomes  exceedingly  difficult,  except  to  the  expe- 
rienced surgeon,  to  expose  it  at  that  point,  consequently  I  would 
advise  you  to  follow  Fergusson's  advice,  and  ligate  the  femoral,  as  it 
would  be  both  less  difficult  and  less  dangerous.  Both  these  vessels 
may  be  easily  exposed  on  the  dead  subject  when  well  injected,  but  ex- 
perience has  convinced  me  that  it  is  much  less  difficult  to  describe 
than  to  perform  such  an  operation  upon  the  superior  portion  of  the 
leg.  In  such  operations  I  have  found  it  very  convenient,  when  you 
ascertain  the  position  of  the  vessel,  to  draw  a  line  directly  over  it, 
either  with  a  pen  or  pencil,  the  length  you  desire  to  make  the  inci- 
sion ;  then  by  the  aid  of  an  assistant  the  skin  should  be  raised,  and 
the  line  followed  by  a  scalpel,  and  less  difficulty  will  be  experienced 
in  completing  the  operation. 

In  aneurism  either  of  the  popliteal  or  lower  portion  of  the  fem- 
oral artery,  the  latter  should  be  ligated  at  the  point  previously  indi- 
cated, but  when  the  tumor  is  located  so  high  upon  the  vessel  that 
the  ligature  cannot  be  applied  at  least  an  inch  and  a  half  below  the 
origin  of  the  profunda  femoris,  then  the  external  iliac  should  be 
preferred.  Almost  every  member  of  this  class  has  enjoyed  the  rare 
privilege  of  seeing  this  operation  performed  successfully  in  two  very 
unpromising  cases.  In  one,  besides  an  enormous  aneurismal  tumor, 
there  was,  on  the  same  side,  a  large  incarcerated  hernia,  which  ren- 
dered the  operation  more  difficult,  and  in  the  other  case  the  sac  was 
not  only  immense,  but  projected  above  Poupart's  ligament,  and  ren- 
dered the  abdominal  parietes  so  tense  that  the  vessel  could  not  be 
seen,  although  the  incision  was  unusually  large.  Abernethy  was 
the  first  to  perform  this  operation  in  1786,  and  although  he  was  un- 
successful, it  was  repeated  in  1806  with  a  better  result. 

When  you  have  determined  to  perform  this  operation,  the  patient 
should  be  kept  in  bed  for  a  few  days;  his  bowels  should  be  relieved 
by  the  exhibition  every  night  of  ten  grains  of  the  extract  of  white 
walnut,  and  only  a  small  quantity  of  simple  food  allowed.  The 
best  position  during  the  operation  is  upon,  the  back,  with  the  head 


LECTURE    XIV. — LIGATION  OF  ARTERIES. 


179 


comfortably  elevated.  The  incision  should  commence  half  an  inch 
above  Poupart's  ligament,  and  in  the  centre  of  the  space  between 
the  anterior  superior  spinous  process  of  the  ilium  and  the  pubis,  and 
extend  upwards  and  outwards  about  an  inch  from  the  iliac  process 
already  mentioned,  and  four  inches  long.  The  first  incision  should 

FIG.  53. 


divide  the  skin  and  subcutaneous  cellular  tissue,  and  after  the  fibres 
of  the  external  oblique  have  been  divided,  you  should  proceed  cau- 
tiously, for  it  is  important  not  to  wound  the  peritoneum,  although  cases 
are  on  record  in  which  it  was  injured  without  a  serious  result.  The 
fibres  of  the  internal  oblique  and  transversalis  muscles  should  be 
raised  by  a  grooved  director  slightly  curved,  and  divided  with  a 
bistoury;  the  peritoneum  should  then  be  detached  from  the  iliac 
fossa  with  the  fingers,  until  the  pulsation  of  the  artery  can  be  felt. 
It  is  large,  and  the  pulsation  is  so  strong  that  it  cannot  be  mistaken 
for  anything  else  in  that  vicinity.  The  vein  is  on  the  inner  side  of 
the  artery,  and  cannot  be  injured.  The  sheath  of  the  vessel  should 
not  be  divided  with  the  knife,  and  I  attribute  my  success  to  that  fact. 
The  aneurismal  needle  should  be  passed  from  within  outward,  and 


180  LECTURES    ON    PRACTICAL    SURGERY. 

when  you  ascertain  that  the  artery  is  upon  the  needle  it  should  be 
disengaged,  and  a  simple  knot  employed  to  obliterate  the  vessel. 
The  ligature  should  occupy  the  inferior  portion  of  the  wound,  and 
the  upper  two-thirds  be  closed  by  the  interrupted  silver  suture.  The 
extremity  should  then  be  treated  as  directed  after  operations  upon 
the  femoral  artery.  I  repeat,  an  effort  should  not  be  made  to  open 
the  sheath  of  the  vessel,  because  it  is  always  unnecessary  and  some- 
times impracticable.  In  both  the  operations  which  you  witnessed 
at  the  hospital  it  was  impossible  to  expose  the  vessel,  and  in  such 
cases,  if  you  believed  it  to  be  important,  nothing  but  disappointment 
could  result  from  the  effort. 

It  sometimes  becomes  necessary  to  ligate  the  internal  iliac,  in  con- 
sequence of  the  existence  either  of  an  aneurism  or  a  wound  of  one  or 
more  of  its  branches,  it  being  generally  impossible  to  expose  and 
ligate  the  bleeding  vessel.  Crampton  and  Syme  both  performed  this 
operation,  but  without  success,  and  the  honor  of  ligating  the  internal 
iliac  successfully  was  reserved  for  Professor  Mott.  The  only  differ- 
ence between  this  operation  and  the  one  just  described,  is  in  the 
incision,  five  or  six  inches  being  required  to  expose  the  vessel  and 
apply  a  ligature  without  difficulty.  The  peritoneum,  in  conse- 
quence of  the  extent  of  the  incision,  is  more  exposed,  and  the  liability 
to  inflammation  increased.  Yet  the  consequences,  resulting  from  the 
arrest  of  circulation  in  the  internal,  are  much  less  serious  than  in  the 
external  iliac  artery.  The  local  and  constitutional  treatment  do  not 
differ.  The  pain  should  be  relieved,  and  the  fever  controlled  as 
already  specified. 

Aneurism  of  the  arteries  of  the  superior  extremity  seldom  occurs 
below  the  axilla,  except  the  traumatic  variety,  and  then,  as  I  have 
already  advised,  both  extremities  should  be  tied,  provided  it  be  pos- 
sible to  determine  what  vessel  is  wounded.  Some  years  ago  I  ap- 
plied a  ligature  upon  the  brachial  artery  to  arrest  the  haemorrhage 
from  a  punctured  wound  below  the  elbow-joint.  A  small  sword- 
cane  had  been  passed  in  front  of  the  bones  through  the  arm,  which 
wounded  a  vessel  of  sufficient  magnitude  to  give  rise  to  a  fatal 
haemorrhage  if  not  controlled.  It  being  impossible  to  decide  which 
vessel  was  wounded,  and  dangerous  to  make  extensive  incisions  in 
that  vicinity,  as  they  might,  should  the  nerves  be  cut,  paralyze  the 
extremity,  and  the  patient  not  being  able  to  lose  more  blood,  he  was 
placed  on  a  sofa  in  my  office  and  the  brachial  artery  ligated.  You 


LECTURE    XIV.  —  LIGATION    OF    ARTERIES. 


181 


will  find  as  much  difficulty  in  placing  a  ligature  upon  this  vessel  as 
upon  either  the  femoral  or  external  iliac.  The  vein  generally  lies  over 
it,  and  the  median  nerve  on  the  ulnar  side.  The  incision  should  be 
two  inches  long  and  upon  the  inner  edge  of  the  biceps  muscle. 


FIG.  54. 


The  artery  is  superficial  and  easily  exposed,  but  still  great  care  is 
required  to  avoid  both  the  vein  and  nerve.  Should  the  former  be 
wounded  nothing  serious  might  result,  yet  should  unpleasant  symp- 
toms arise  it  is  very  gratifying  to  know  that  the  operation  was 
properly  performed.  I  have  tied  this  artery  repeatedly,  and  on  one 
occasion  the  nerve  was  directly  over  the  vessel,  and  was  much  more 
troublesome  than  the  vein. 

When  the  radial  or  ulnar  artery  is  wounded  near  the  wrist,  and 
the  hemorrhage  cannot  be  controlled  by  pressure,  then  the  wound 
should  be  enlarged  and  the  vessel  secured  as  directed  under  such 
circumstances. 

In  wounds  of  the  hand,  particularly  if  the  haemorrhage  is  from  the 
palmar  arch,  and  cannot  be  readily  controlled  by  pressure,  then 
both  the  radial  and  ulnar  arteries  should  be  tied  near  the  wrist. 
Three  years  ago  a  young  man  came  to  San  Francisco  from  the 
vicinity  of  Marysville,  with  a  false  aneurism  near  the  lower  por- 
tion of  the  axilla,  produced  by  an  accidental  knife-wound.  The 
tumor  was  about  the  size  of  a  man's  fist,  pulsated  strongly,  and 
occupied  a  dangerous  location.  An  operation  was  the  only  alterna- 
tive. The  circulation  in  the  vessel  being  arrested  by  Dr.  Fourgeaud, 
the  sac  was  opened  and  the  necessary  ligatures  applied.  The  open- 
ing in  the  vessel  was  small,  which  in  that  location  was  just  as  dan- 
gerous as  if  it  had  been  more  extensively  wounded.  In  such  cases 
spring  artery  forceps  should  always  be  at  hand,  so  that  should  com- 
pression fail  the  hemorrhage  can  be  arrested  until  a  ligature  is 


182  LECTURES    ON    PRACTICAL    SURGERY. 

applied.     The  incision  should  be  free,  so  as  to  prevent  any  difficulty 
being  experienced  in  exposing  the  wound. 

The  first  operation  for  aneurism  of  the  axillary  artery  was  per- 
formed by  Pelletier  in  1786.  He  dissected  up  the  clavicular  origin 
of  the  pectoralis  major  muscle.  Keate  performed  the  same  opera- 
tion in  1800,  and  Chamberlain  in  1815,  in  every  case  without  suc- 
cess. Besides  being  improper  in  a  great  majority  of  cases,  it  is  both 
exceedingly  difficult  and  dangerous.  Profuse  haemorrhage  should 
be  expected  from  the  branches  of  the  thoracica  humeralis.  The  sub- 
clavian  vein  lies  over  the  artery,  and  would  be  endangered  by  the 
operation,  besides  which,  one  of  the  numerous  nerves  which  form  the 
axillary  plexus  might  be  mistaken  for  the  artery.  It  is,  therefore, 

FIG.  55. 


much  safer  and  easier  in  such  cases  to  apply  a  ligature  upon  the  sub- 
clavian  above  the  clavicle,  and  after  it  has  passed  behind  the  scalenus 
anticus  muscle.  At  that  point  it  is  separated  from  the  vein.  The 
vessel  is  more  healthy  than  in  the  vicinity  of  the  tumor,  will  bear  a 
ligature  better,  and  will  resist  the  force  of  a  large  column  of  blood 
with  much  more  certainty. 

Ramsden  ligated  the  subclavian  in  1808,  and  established  the  prac- 
ticability of  the  procedure,  but  the  honor  always  connected  with 


LECTURE    XIV.  —  LIGATION    OF    CAROTID.  183 

success  was  reserved  for  Prof.  Post,  of  New  York,  in  1817.  The 
patient  should  be  placed  upon  the  back,  with  the  head  lower  than 
the  body,  so  as  to  expose  and  render  tense  the  parts  to  be  divided. 
The  first  incision  should  be  made  near  and  upon  the  upper  side  of 
the  clavicle,  and  should  extend  from  the  margin  of  the  insertion  of 
the  sterno-cleido-mastoideus  muscle  to  that  of  the  trapezius,  which 
is  usually  about  three  inches.  Another  incision  perpendicular  to  the 
first,  and  of  about  the  same  length,  should  extend  from  the  centre  of 
this  parallel  with  the  edge  of  the  sterno-cleido-mastoideus.  The  flaps 
thus  made  should  be  dissected  and  thrown  back.  The  omo-hyoid 
muscle  should  then  be  divided,  and  the  scalenus  anticus  exposed, 
which  is  traced  to  its  insertion  into  the  first  rib ;  on  the  outside  and 
near  the  muscle,  you  will  find  the  subclavian  artery.  In  ligating 
either  this  or  any  other  artery  you  should  be  guided  by  the  pulsation, 
and  that  will  protect  you  from  the  error  sometimes  committed  of  mis- 
taking a  nerve  for  an  artery.  It  is  useless  to  say  anything  more 
about  the  instruments  used,  the  size  of  the  ligature,  and  the  subse- 
quent treatment,  as  you  are  all  familiar  with  everything  of  that 
character. 

Aneurism  of  the  carotid  artery  occurs  occasionally  sufficiently 
high  upon  the  neck  to  require  a  ligature.  You  will,  however,  find 
it  more  frequently  necessary  to  ligate  this  vessel  to  arrest  haemor- 
rhage from  the  mouth,  or  to  enable  you  to  remove  either  the  parotid 
gland  or  tumors  from  the  neck  or  throat,  than  for  aneurism.  I  have 
ligated  both  the  common  and  external  carotids  frequently,  and  in 
every  case  successfully. 

Paralysis  of  one  side  followed  a  ligation  of  the  common  carotid, 
in  this  city,  which  was  performed  to  enable  me  to  remove  a  large 
malignant  tumor  from  the  upper  part  of  the  neck  and  face.  It  con- 
tinued for  several  months,  and  until  the  patient  died  of  cancer  of 
the  stomach.  Sir  Astley  Cooper  was  the  first  to  perform  this  opera- 
tion successfully,  in  1808,  and  since  that  time  it  has  been  performed 
very  frequently  and  successfully.  The  patient  should  be  placed  upon 
the  back,  with  head  low  and  turned  towards  the  opposite  side,  and 
if  the  operation  is  performed  either  to  remove  a  tumor  or  to  arrest 
haemorrhage,  the  artery  should  be  ligated  about  half-way  between  the 
ear  and  clavicle.  An  incision  should  be  made  two  inches  and  a  half 
in  length,  near  the  inner  edge  of  the  sterno-cleido-mastoideus  muscle. 
At  that  point  the  vessel  is  covered  only  by  the  skin,  platysma 


184          LECTURES  ON  PRACTICAL  SURGERY. 

myoides,  and  fascia,  and  is  easily  exposed  by  drawing  the  muscle 
backwards,  and  lacerating  the  cellular  tissue,  either  with  a  director, 
or  with  the  handle  of  a  scalpel.  The  sheath  of  the  vessels  should 
then  be  opened  on  the  inner  side,  to  avoid  the  vein,  which  partially 
conceals  the  artery,  as  well  as  the  descendens  nerve,  which  lies  upon 
the  centre  of  the  sheath.  The  convexity  of  the  needle  should  be 
turned  towards  the  vein.  If  the  sheath  be  opened,  and  the  needle 
properly  directed,  the  par  vagum  is  perfectly  safe,  being  posterior  to 
the  artery.  Lower  upon  the  neck  the  carotid  is  covered  by  the  sterno- 
mastoid  and  sterno-thyroid  muscles ;  the  omo-  hyoid  will  be  ex- 
posed where  it  crosses  the  vessels,  and  generally  requires  the  attention 
of  an  assistant,  who  should  be  directed  to  draw  it  downwards.  The 
same  care  should  be  observed,  both  in  opening  the  sheath  and  apply- 
ing the  ligature,  as  previously  advised,  and  in  this  location  it  is  ex- 
ceedingly important,  not  only  to  place  the  ligature  in  the  most  depend- 
ent portion  of  the  wound,  but  also  to  introduce  a  sufficient  quantity 
of  wet  lint  to  allow  the  secretions  to  escape  readily,  both  before  and 
after  suppuration  is  established. 

Cases  occasionally  occur  in  which  it  is  considered  both  right  and 
proper  to  ligate  the  arteria  innominate,  although  until  recently  it  has 
never  been  performed  successfully.  Dr.  Smyth,  of  New  Orleans, 
during  the  late  war  ligated  both  the  vertebral  and  the  innominate 
successfully,  and  consequently  deserves  the  credit  of  having  accom- 
plished what  all  his  predecessors  and  contemporaries  considered 
impossible.  Dr.  Mott  ligated  this  vessel  for  the  first  time  in  1818. 
His  patient  died  on  the  twenty-seventh  day,  of  haemorrhage. 
Graefe's  patient  lived  two  months,  and  shared  the  same  fate.  A  few 
years  since,  Dr.  Cooper,  of  this  city,  ligated  this  vessel  with  the  same 
result.  This  operation  is  not  difficult  to  perform,  but  the  result  has 
been  anything  but  satisfactory,  yet  under  favorable  circumstances, 
with  the  prestige  of  one  successful  case,  it  may  be  justifiable.  Make 
two  incisions  three  inches  in  length,  the  first  directly  upwards  on  the 
inner  edge  of  the  sterno-cleido-mastoideus  muscle,  and  the  second 
from  the  same  point,  above  the  clavicle,  so  as  to  divide  the  sterno- 
mastoid,  sterno-hyoid,  and  sterno-thyroid  muscles,  and  when  the 
flap  is  turned  up  the  sheath  of  the  common  carotid  will  be  visible. 
This  should  be  opened,  and  the  artery  followed  downwards  until  the 
innominate  is  exposed.  The  convexity  of  the  needle  should  be 
turned  towards  the  sternum,  to  avoid  the  vein  and  pleura.  Since 


LECTURE    XIV.  —  ANEURISM    OF    TEMPORAL.  185 

Dr.  Smyth  found  it  necessary  to  the  success  of  the  operation  to  ligate 
the  vertebral,  I  think  both  vessels  should  be  secured  at  the  same 
time. 

You  may  find  it  necessary  to  ligate  the  temporal  artery  for  aneu- 
rism produced  by  arteriotomy.  In  such  cases  a  division  of  the 
artery,  and  the  application  of  a  compress  and  bandage,  will  control 
any  difficulty  of  that  character.  Should  that  fail,  the  skin  should 
be  divided  transversely  across  the  vessel,  and  a  ligature  passed  under 
the  artery  with  a  curved  needle,  which,  when  tightened,  will  arrest 
the  circulation  in  the  vessel.  I  have  but  once  found  it  necessary  to 
ligate  this  vessel,  having  usually  divided  it  transversely  with  a 
scalpel,  and  then  with  a  compress  and  bandage  I  experienced  no 
difficulty  in  controlling  the  haemorrhage. 

The  next  lecture  will  be  upon  hernia. 

LI  B  R  A  E  Y 

UNIVERSITY   OF 

CALIFORNIA. 


186  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE  XV. 

GENTLEMEN:  The  only  variety  of  tumor  that  remains  to  be  de- 
scribed is  hernia,  to  which  I  propose  to  devote  this  lecture.  The 
protrusion  of  any  portion  of  the  contents  of  a  cavity  through  the  pari- 
etes,  the  integument  remaining  entire,  is  called  a  hernia.  Formerly 
it  received  the  name  of  rupture,  because  it  was  supposed  that  a  lacer- 
ation was  necessary  to  enable  the  viscera  to  escape.  In  most  cases 
the  protrusion  takes  place  through  the  natural  openings, — those  in- 
tended for  the  escape  of  the  testicles,  the  umbilical  cord,  and  the 
femoral  vessels.  The  parietes  of  the  abdomen  are  composed  of  the 
skin,  cellular  tissue,  superficial  fascia,  the  external  and  internal  ob- 
lique, transversales  recti,  and  pyramidales  muscles,  as  well  as  the 
fascia  transversal  is  and  peritoneum.  The  muscles  of  the  abdomen 
extend  from  the  thorax,  arid  unite  at  and  form  Poupart's  ligament, 
which  is  large,  dense,  and  strong,  and  extends  from  the  superior  an- 
terior spinous  process  of  the  ilium  obliquely  downwards  to  the  pubis. 
It  is  of  no  consequence  whether  we  say  that  the  ligament  is  formed 
by  the  union  of  these  tendons,  or  serves  only  as  a  point  of  attach- 
ment, and  protects  the  femoral  vessels,  the  artery,  vein,  and  nerve 
when  passing  from  the  abdomen  to  the  thigh.  Another  very  im- 
portant part  in  connection  with  this  subject  is  the  epigastric  artery  ; 
it  arises  from  the  external  iliac,  runs  upwards  between  the  abdomi- 
nal rings,  and  constitutes  from  its  position  one  of  the  dangers  in 
operations  for  hernia.  It  is  located  between  the  fascia  trans  versa- 
lis  and  peritoneum,  and  could  not  be  ligated,  if  wounded,  without 
endangering  the  life  of  the  patient.  The  abdominal  rings  were  men- 
tioned ;  they  are  called  internal  and  external,  and  the  canal  which 
connects  them  the  inguinal.  The  internal  ring,  which  is  ordinarily 
closed  by  cellular  substance,  can  be  found  midway  between  the 
spinous  process  of  the  ilium  and  the  pubis,  and  about  an  inch  above 
Poupart's  ligament.  It  is  formed  by  the  internal  oblique  and  trans- 
versalis  muscles,  and  the  testicle  in  its  descent  carries  with  it  some 
muscular  fibres,  which  constitute  the  cremaster  muscle.  After  passing 


LECTURE    XV.  —  HERNIA.  187 

through  the  internal  ring,  it  traverses  the  inguinal  canal,  which  is 
about  two  inches  and  a  half  in  length ;  the  floor  or  posterior  surface 
of  it  is  formed  by  the  conjoined  tendons  of  the  internal  oblique 
and  transversalis  muscles,  and  the  canal  is  completed  by  that  of  the 
external  oblique.  The  external  ring  is  a  mere  slit  in  the  tendon  of 
the  last-named  muscle,  is  about  an  inch  and  a  quarter  in  length,  and  is 
covered  only  by  the  skin,  cellular  tissue,  and  superficial  fascia.  After 
the  testicle  passes  through  this  it  soon  reaches  the  scrotum.  In 
hernia,  neither  the  fascia  transversalis  nor  the  peritoneum  is  ruptured, 
being  only  carried  down  in  front  of  and  covering  the  protruding 
part.  The  descent  of  the  testicle  usually  occurs  about  a  month 
before  the  birth  of  the  child,  and  should  the  internal  ring  and  in- 
guinal canal  not  be  closed,  a  portion  of  the  abdominal  contents  may 
descend  with  it  to  the  scrotum,  and  form  what  is  called  congenital 
hernia,  the  existence  and  character  of  which  was  first  demonstrated 
in  the  dissecting-room  by  Dr.  William  Hunter.  The  contents  of  a 
hernial  tumor  may  be  either  peritoneum,  intestine,  or  omentum,  or 
both  of  the  last  mentioned.  When  the  intestine  protrudes  it  is  called 
enterocele,  when  the  omentum  escapes  epiplocele,  and  enteroepiplo- 
cele  when  the  sac  contains  both  omentum  and  intestine.  The  size 
varies  as  in  peritoneal  hernia,  from  that  of  a  cherry  to  a  tumor  as 
large  as  a  man's  head,  and  may  contain  only  a  portion  of  the  perito- 
neum, or  half  of  the  intestinal  canal. 

Causes. — These  are  divided  into  predisposing  and  exciting.  In 
some  cases  there  exists  an  hereditary  predisposition  to  hernia,  as  it 
frequently  occurs  in  several  members  of  the  same  family,  and  un- 
doubtedly depends  on  a  want  of  constitutional  vigor.  It  frequently 
occurs  in  old  age,  and  in  chronic  diseases  accompanied  by  emacia- 
tion, debility,  and  consequently  relaxation  of  the  tissues  generally. 

The  exciting  causes  are  violent  muscular  exertions,  such  as  lift- 
ing heavy  weights,  jumping,  and  wrestling.  Sometimes  it  is  pro- 
duced by  a  violent  and  protracted  cough,  and  it  often  appears  in 
children  during  the  existence  of  hooping-cough  or  bronchitis. 

Inguinal  hernia  either  follows  the  direction  of  the  spermatic  cord, 
or  passes  directly  through  the  external  ring.  The  former  is  called 
inguinal,  and  the  latter  ventro-inguinal.  In  such  cases  when  the 
tumor  remains  in  the  groin  it  is  called  bubonocele,  and  when  it  de- 
scends lower,  either  scrotal  or  pndendal,  according  to  the  sex  of  the 
patient.  When  a  decided  predisposition  exists,  it  occurs  more  fre- 


188          LECTURES  ON  PRACTICAL  SURGERY. 

quently  on  the  right  than  the  left  side,  which  may  result  from  the 
muscles  on  that  side  being  more  powerful  than  those  on  the  left. 

Hernia  is  said  to  be  reducible,  when  the  contents  of  the  sac  can 
be  returned  into  the  abdominal  cavity  without  an  operation,  and  in- 
carcerated when  they  cannot  be  replaced,  and  yet  the  intestine  con- 
tinues to  perform  its  function,  although  it  occupies  an  unnatural 
position.  The  patient  operated  upon  for  aneurism  of  the  femoral 
artery,  had  suffered  from  this  difficulty  for  six  years,  although  he  en- 
joyed good  general  health.  A  hernia  is  strangulated  when  there  is 
sufficient  pressure  made  upon  the  protruding  part  to  destroy  its 
function;  or  in  other  words,  when  the  contents  of  the  intestinal  canal 
cannot  pass  through  the  portion  which  is  contained  in  the  sac  and 
forms  the  tumor,  it  is  strangulated.  In  every  variety  of  hernia,  if 
the  pressure  be  sufficient  to  produce  inflammation,  lymph  will  soon 
be  effused,  and  when  organized  the  parts  cannot  be  returned,  as  in 
incarcerated  hernia ;  but  when  the  pressure  is  sufficient  to  arrest  the 
circulation  in  the  vessel  by  which  the  protruding  part  is  supplied, 
then  without  proper  treatment  mortification  must  result.  Strangula- 
tion may  be  produced  either  by  the  rigidity  of  the  opening,  or  by  in- 
duration of  the  neck  of  the  sac,  particularly  when  an  additional  por- 
tion of  either  omentum  or  intestine  has  escaped.  As  already  stated, 
the  contents  of  a  hernial  sac  may  be  either  peritoneum,  intestine,  or 
omentum.  In  inguinal  hernia  a  portion  of  the  ileum  is  sometimes 
found  alone,  but  more  frequently  it  is  united  with  more  or  less 
omentum  in  proportion  to  the  size  of  the  tumor.  Cases,  however, 
occur  in  which  the  caecum,  colon,  and  indeed  almost  the  entire  ali- 
mentary canal  escapes,  and  may  even  pass  into  the  scrotum.  This 
occurrence  is  more  frequent  in  double  hernia  when  neglected. 

Symptoms. — The  symptoms  of  reducible  hernia  are,  1st,  A  tumor 
upon  the  upper  part  of  the  thigh  at  the  groin,  the  umbilicus,  or  indeed 
upon  any  portion  of  the  abdomen,  which  is  elastic,  colorless,  without 
pulsation,  and  which  may  be  returned  into  the  cavity  either  by  pres- 
sure or  position,  or  both  combined.  When  the  patient  coughs,  there 
is  a  decided  downward  impulse  felt  through  a  hernial  tumor,  not  in 
any  other.  Generally  but  little  difficulty  will  be  experienced  in 
forming  a  diagnosis,  except  when  hernia  is  complicated  with  hydro- 
eel  e,  which  is  not  uncommon,  particularly  in  congenital  cases. 
Several  members  of  this  class  were  present  when  the  exploring 
needle  was  used  for  the  purpose  of  determining  the  character  of  such 


LECTURE    XV.  —  HERNIA. 


189 


a  case.  The  boy  was  about  seven  years  of  age,  and  had  suffered  half 
that  time  from  an  enlargement  of  the  scrotum.  After  the  use  of  the 
exploring  needle  a  puncture  was  made  with  a  lancet,  and  after  the 
escape  of  the  serum,  a  portion  of  omentum  protruded,  so  as  to  render 
it  difficult  to  close  the  wound.  I  took  hold  of  it  with  the  forceps, 
and  finding  but  little  resistance  I  removed  a  portion,  an  inch  wide, 

FIG.  56. 


and  nearly  a  foot  in  length,  which  left  the  sac  empty ;  the  wound  was 
then  carefully  closed,  and  the  patient  placed  on  his  back  with  the 
head  and  knees  both  elevated ;  he  was  kept  in  that  position  for  three 
or  four  days,  and  on  the  seventh  after  the  operation  he  returned  to 
the  country,  without  having  suffered  the  slightest  inconvenience  from 
anything  except  the  confinement.  The  boy  is  now  in  good  health, 
and  cured  of  both  hydrocele  and  hernia. 

Strangulated  hernia  is  a  very  serious  difficulty,  and  one  that  should 


190  LECTURES    ON    PRACTICAL    SURGERY. 

be  well  understood,  as  no  time  is  allowed  for  preparation.  The  pa- 
tient usually  complains  of  a  distressing  pain  in  the  umbilical  region, 
which  is  accompanied  with  constipation  and  either  sickness  of  the 
stomach  or  vomiting.  The  constitutional  symptoms  are  of  a  still 
more  serious  character.  The  pulse  is  small  and  frequent,  the  ex- 
tremities are  cold,  the  face  pale,  and  the  features  shrunken,  with  an 
expression  of  the  most  intense  anxiety,  accompanied  with  extreme 
restlessness.  Whenever  you  find  a  patient  in  that  condition,  either 
male  or  female,  if  any  swelling  has  either  existed  for  some  time  or 
has  recently  appeared,  where  you  would  expect  to  find  a  tumor  of 
that  character,  you  should  act  promptly,  because  death  almost  always 
results  when  a  strangulated  hernia  is  mistaken  for  some  other  diffi- 
culty. 

Constipation  does  not  always  depend  upon  the  intestinal  canal 
being  obstructed,  as  the  same  difficulty  results  from  strangulation  of 
the  omentum,  and  is  no  doubt  produced  by  the  inverted  action 
which  is  inseparable  from  pressure  upon  either  the  intestines  or  the 
omentum.  When  a  case  of  this  character  has  not  been  properly 
treated,  inflammation  takes  place,  which  may  be  either  confined  to 
the  hernial  sac  or  may  extend  to  the  peritoneum,  and  may  prove 
speedily  fatal.  When  local,  after  a  greater  or  less  period,  according 
to  the  amount  of  pressure  and  the  constitutional  vigor  of  the  patient, 
the  integument  inflames,  and  when  either  the  skin  ulcerates  or  an 
incision  is  made,  the  intestine  will  be  found  mortified,  with  an  open- 
ing which  is  called  an  artificial  anus. 

Before  the  discovery  of  chloroform,  I  operated  frequently  for 
strangulated  hernia,  but  during  the  last  thirteen  years  I  have  only 
operated  upon  two  cases,  and  that  might  have  been  avoided  if  the 
patients  had  received  early  and  proper  attention. 

Treatment. — Having  described  the  different  varieties  of  hernia  I 
will  now  give  you  the  treatment  which  they  require.  In  the  con- 
genital, and  when  reducible,  at  the  age  of  three  or  four  months, 
which  is  as  soon  as  the  skin  will  bear  the  pressure  of  a  truss,  one 
should  be  applied,  no  matter  how  simple,  if  it  only  prevents  the 
descent  of  the  hernia,  and  it  should  be  continued  for  several  months 
after  the  tumor  has  disappeared,  in  order  to  prevent  a  recurrence. 
It  is  sometimes  necessary  for  a  child  to  wear  a  truss  for  two  or  three 
years  before  a  radical  cure  is  effected. 

In  reducible  hernia  in  the  adult,  if  Chase's  truss  is  applied,  prop- 


LECTURE    XV. — CURE    OF    HERNIA.  191 

erly  adjusted,  and  constantly  worn,  particularly  if  the  patient  be 
young  and  vigorous,  you  can  calculate  with  almost  a  certainty  on 
effecting  a  cure.  It  consists  of  a  block  of  wood  attached  to  a  spring 
with  a  flexible  neck,  so  that  it  can  be  bent  to  suit  any  case  either  of 
inguinal  or  femoral  hernia.  Should  ulceration  of  the  skin  be  threat- 
ened by  the  pressure  of  the  block,  six  or  eight  folds  of  new  silk, 
larger  than  the  block,  should  be  placed  between  it  and  the  skin  ;  by 
which  arrangement  the  effect  both  of  the  pressure  and  friction  is  re- 
moved. The  internal  layer  of  the  compress  adheres  to  the  skin,  the 
external  to  the  block,  and  the  remainder  not  being  stitched  together 
glide  readily  over  each  other,  whilst  those  in  contact  both  with  the 
skin  and  truss  remain  stationary.  This  truss  should  be  worn  for 
at  least  two  years,  and  should  that  fail  then  you  may  perform  the 
operation  which  was  so  popular  a  few  years  ago,  for  the  radical 
cure  of  reducible  hernia,  which  consists  in  invaginating  the  scrotum 
and  confining  it  by  two  strong  ligatures  in  the  external  abdominal 
ring,  until  adhesions  take  place  sufficiently  strong  to  close  the  open- 
ing. I  have  performed  several  of  the  operations  recommended,  but 
lately  I  have  adopted  the  following  simple  method,  when  the  open- 
ing is  so  large  that  a  truss,  no  matter  how  well  applied,  will  not 
prevent  the  escape  of  the  contents  of  the  sac.  In  such  cases  the 
upper  portion  of  the  scrotum  should  be  pushed  up  into  the  ring 
with  the  fore  and  middle  fingers  of  the  left  hand,  and  when  within 
the  external  ring  a  large  curved  needle,  armed  with  a  strong  liga- 
ture, should  be  passed  through  the  skin  above  the  edge  of  the  ab- 
dominal ring  as  well  as  the  scrotum,  until  the  point  reaches  the 
finger;  then  it  should  be  passed  under  the  extremity  for  about  half 
an  inch  and  brought  out  about  an  inch  from  the  point  of  insertion. 
If  the  opening  be  large,  three  points  of  the  interrupted  suture  should 
be  inserted,  and  a  compress  the  size  of  the  thumb  placed  upon  the 
space  between  the  extremities  of  the  ligatures,  and  secured  so  firmly 
that  it  cannot  be  displaced.  The  ligatures  should  be  allowed  to 
remain  from  six  to  twelve  days,  according  to  the  degree  of  inflam- 
mation that  may  result  from  their  presence.  A  truss  should  then 
be  applied  and  worn  as  long  as  necessary,  which  is  generally  during 
the  life  of  the  patient,  as  but  few  permanent  cures  are  made  by  such 
operations. 

Incarcerated  Hernia. — Formerly  the  victims  of  this  unpleasant 
difficulty  were  placed  in  a  horizontal  position,  and  starved  to  exces- 


192          LECTURES  ON  PRACTICAL  SURGERY. 

sive  emaciation,  with  the  hope  that  the  adhesions  might  yield  suffi- 
ciently to  allow  the  tumor  to  return.  In  such  cases  it  is  useless  to 
annoy  the  patient  by  efforts  at  reduction,  and  the  treatment  should 
consist  of  palliatives,  such  as  temperance,  with  the  application  of  a 
suitable  suspensory  bandage. 

Strangulated  hernia  is  not  only  accompanied  with  pain  and  the 
other  symptoms  enumerated,  but  is  also  attended  with  such  great 
and  immediate  danger  that  an  effort  should  be  made  to  reduce  it  by 
the  taxis  as  soon  as  possible. 

The  patient  should  be  placed  upon  the  back,  with  the  head  and 
knees  both  sufficiently  elevated  to  relax  the  abdominal  muscles. 
Chloroform  should  then  be  administered  until  its  full  effect  is  pro- 
duced, then  if  it  be  a  scrotal  hernia  take  the  tumor  either  in  one  or 
both  hands  and  draw  it  gently  outwards,  and  at  the  same  time 
make  pressure  with  the  thumbs  near  the  external  ring ;  generally 
the  gaseous  contents  will  return,  and  soon  will  be  followed  by  the 
more  solid  portion.  It  is  neither  safe  nor  proper  to  apply  much 
force.  Skill  is  more  important  than  strength,  and  sometimes  it  is 
necessary  to  exercise  great  patience,  yet  the  efforts  to  reduce  the 
hernia  should  not  be  too  long  continued,  as  they  might  hasten  the 
development  of  dangerous  inflammation.  I  have  frequently  when 
called  at  night,  where  the  symptoms  of  strangulation  were  neither 
distressing  nor  violent,  after  administering  half  a  grain  of  sulphate 
of  morphia,  placed  the  patient  on  the  back,  and  in  the  morning 
would  find  that  the  tumor  had  disappeared  with  the  symptoms 
which  it  produced.  Not  more  than  two  months  since  I  visited  a 
child,  at  night,  with  strangulated  congenital  hernia ;  as  the  parents 
were  unwilling  to  have  an  anaesthetic  administered,  and  the  reduc- 
tion being  otherwise  impossible  in  consequence  of  the  resistance 
made  by  the  patient,  a  sufficient  quantity  of  Dover's  powder  was 
given  to  produce  sleep,  and  in  the  morning  the  tumor  had  disap- 
peared. In  such  cases  there  is  nothing  equal  to  chloroform ;  it  pro- 
duces more  complete  relaxation  than  all  the  other  medicinal  agents 
combined  that  have  either  been  employed  or  recommended,  and  in 
consequence  of  the  benefit  derived  from  its  use  I  have  only  found  it 
necessary  to  perform  two  operations  for  hernia  in  this  city,  and  I 
have  no  doubt  that  if  they  had  been  treated  properly  it  could  have 
been  in  these  cases  avoided.  When  the  taxis  fails  an  operation 
should  be  performed  as  soon  as  possible,  and  when  that  is  necessary 


LECTURE    XV.  —  OPERATION    FOR    HERNIA.  193 

the  part  should  be  shaved,  and  after  the  exhibition  of  an  anaesthetic 
the  patient  should  be  placed  near  the  side  of  the  bed,  and  the  incision 
made  the  entire  length  of  the  tumor.  In  making  the  first  incision 
I  prefer  to  raise  the  skin  by  the  aid  of  an  assistant,  and  divide  it  by 
one  stroke  of  a  bistoury  to  the  extent  which  may  be  necessary  to 
expose  the  sac.  I  adopted  that  method  in  consequence  of  having 
seen  Jobert,  a  distinguished  surgeon  of  the  St.  Louis  Hospital,  in 
Paris,  cut  through  the  skin,  cellular  tissue,  the  sac,  and  all  the  coats 
of  the  intestine  by  the  first  incision,  which  would,  in  private  practice, 
destroy  the  reputation  of  any  young  surgeon.  After  the  division  of 
the  skin  and  subcutaneous  cellular  tissue,  you  may  open  the  sac 
either  slowly  or  by  passing  the  knife  gently  in  the  direction  of  the 
external  wound,  dividing  a  thin  layer  each  time  until  the  intestine 
is  exposed,  or  you  may  raise  a  thin  layer  of  the  sac  with  the  forceps 
and  incise  it  either  with  a  scalpel  or  scissors,  so  as  to  admit  a 
grooved  director,  and  proceed  to  divide  in  the  same  manner  layer 
after  layer  until  the  contents  of  the  sac  are  exposed.  Usually  when 
that  is  accomplished  serum,  either  bloody  or  dark  in  color,  escapes, 
showing  that  the  sac  has  been  opened ;  the  opening  should  be  en- 
larged until  the  part  strangulated  is  exposed.  The  first  operation 
of  this  character  which  I  performed  was  for  umbilical  hernia.  It 
had  been  strangulated  two  days,  and  so  soon  as  the  sac  was  opened 
so  large  a  quantity  of  dark  serum  escaped  that  I  believed  the  intes- 
tine was  wounded,  which  was  found,  however,  to  be  dark-colored  but 
not  mortified,  and  after  dividing  the  stricture- it  was  easily  returned, 
and  the  patient  recovered. 

After  opening  the  sac  and  exposing  the  intestine,  the  forefinger 
should  be  passed  through  the  internal  ring,  between  it  and  the 
protruding  part,  and  the  stricture  divided  either  with  a  probe- 
pointed  bistoury  or  blunt  scissors. 

The  incision  should  be  made  directly  upwards,  so  as  to  avoid  the 
epigastric  artery,  which  in  ventro-inguinal  hernia  is  on  the  external 
or  iliac  side  of  the  tumor.  I  always,  before  making  the  incision, 
endeavor  to  ascertain  the  position  of  the  artery,  so  that  if  its  loca- 
tion be  abnormal  it  may  be  avoided.  After  the  stricture  is  divided, 
the  condition  of  the  protruding  part  should  be  ascertained.  Should 
it  be  red,  livid,  or  even  black,  if  it  has  not  been  long  strangulated, 
and  no  adhesions  exist,  it  should  be  returned.  Even  when  adhe- 
sions have  taken  place,  if  they  can  be  easily  destroyed,  it  should  be 

13 


194  LECTURES    ON    PRACTICAL    SURGERY. 

done  and  the  parts  returned.  But  if  mortification  has  taken  place, 
the  part  should  be  allowed  to  remain  externally,  and  if  the  adhe- 
sions are  not  sufficient,  a  suture  should  be  employed  to  prevent  the 
return  and  give  the  patient  the  benefit  of  an  artificial  anus. 

After  the  operation  has  been  completed,  a  small  portion  of  wet 
lint  should  be  placed  in  the  lower  extremity  of  the  wound,  and  the 
remainder  closed  by  the  interrupted  silver  suture,  and  treated  sub- 
sequently as  an  ordinary  wound.  When  mortification  is  either 
imminent  or  has  already  occurred,  the  wound  should  be  left  open, 
so  as  to  allow  the  contents  of  the  intestines  to  escape,  until  a  com- 
munication between  the  extremities  can  be  effected  by  a  surgical 
operation.  The  forceps  invented  by  Dupuytren  are  superior  to  any 
other  instrument  that  has  been  used  for  that  purpose.  The  extrem- 
ities of  the  blades  are  round  and  flat,  and  about  an  inch  in  diameter. 
One  blade  being  passed  into  each  extremity  of  the  intestine,  they 
should  be  closed  so  as  to  bring  the  serous  surfaces  in  contact,  but  not 
with  sufficient  force  to  destroy  their  vitality.  In  two  or  three  days 
sufficient  inflammation  is  produced  to  unite  the  serous  surfaces,  and 
then  the  pressure  should  be  gradually  increased,  until  the  coats  of  the 
intestine  subjected  to  the  pressure  are  destroyed.  I  have  watched 
with  great  interest  the  use  of  this  instrument  in  the  hands  of  the 
inventor,  and  was  not  disappointed  in  the  result.  So  soon  as  the 
contents  of  the  intestine  can  pass  readily  through  the  opening  made 
by  the  instrument,  the  other  speedily  closes. 

Femoral  Hernia. — It  is  more  difficult  to.  diagnose  femoral  than 
any  other  variety  of  hernia.  It  may  be  mistaken,  when  reducible, 
for  psoas  abscess,  although  it  is  generally  smaller,  returns  less  readily, 
is  less  elastic,  and  is  not  accompanied  with  the  same  constitutional 
symptoms.  It  is  much  less  painful  than  a  bubo,  and  the  pulsation 
that  always  exists  in  an  aneurism  of  the  artery  would  enable  you  to 
distinguish  it  from  that  difficulty.  The  contents  of  a  femoral  hernia 
pass  through  the  imperfectly  closed  space  that  intervenes  between 
the  femoral  vessels  and  Gimbernat's  ligament,  which  is  formed  by  the 
iliac  and  transversalis  fascia,  and  extends  from  Poupart's  ligament 
to  the  crest  and  ramus  of  the  pubis,  and  about  an  inch  from  the 
former.  On  the  iliac  side  it  presents  a  crescentic  edge  or  margin, 
which  in  strangulated  hernia  constitutes  the  seat  of  stricture.  The 
directions  given,  when  speaking  of  the  taxis,  will  apply  to  every 
variety  of  this  difficulty,  and  it  now  only  remains  to  describe  the 


LECTURE    XV.  —  HERNIA.  195 

operations  required  in  peritoneal,  umbilical,  and  crural  hernia.  In 
the  latter  the  incisions  should  be  in  the  shape  of  a  T,  and  the  trans- 
verse cut  should  be  below,  but  near,  Poupart's  ligament.  Great  care 
should  be  exercised  in  this  operation,  as  the  sac  is  not  covered  by  a 
dense  fascia,  but  only  surrounded  by  the  skin,  cellular  substance,  fat, 
and  lymphatic  ganglions,  which  are  located  between  the  pectineus 
and  sartorius  muscles.  The  fascise  only  are,  therefore,  important, 
as  constituting  the  seat  of  stricture.  After  the  protruding  part  is 
exposed,  the  finger  should  be  passed  up  on  the  inner  side,  and  with 
it  a  probe-pointed  bistoury  directed  inwards,  to  avoid  the  obturator 
artery.  The  ligament  should  be  divided  sufficiently  to  allow  the 
hernia  to  be  reduced,  and  the  wound  dressed  as  already  directed. 

Umbilical  Hernia. — This  is  almost  always  congenital,  and  occurs 
more'frequently  in  children  of  African  descent  than  in  those  of  any 
other  variety  of  the  human  family.  If  the  general  health  of  the 
child  be  good,  it  is  easily  cured  by  a  gum-elastic  bandage,  without 
the  use  of  a  compress.  This  should  be  about  six  inches  in  width, 
and  never  removed,  except  when  proper  attention  to  cleanliness  ren- 
ders it  necessary,  until  a  cure  is  effected.  In  children,  I  have  never 
failed  to  effect  a  radical  cure  by  the  use  of  this  bandage.  Should  um- 
bilical hernia  be  neglected,  it  frequently  becomes  very  large,  and  may 
when  an  additional  portion  of  omentum  or  intestine  is  forced  into  the 
sac,  become  strangulated.  A  crucial  incision  should  be  made,  and 
the  same  precautions  taken  which  were  previously  mentioned,  except 
that  there  being  no  vessels  of  magnitude  in  that  vicinity,  the  stric- 
ture may  be  divided  in  any  direction,  and  the  part  returned,  if  in  a 
proper  condition,  as  already  specified. 

Ventral  Hernia. — Ventral  hernia  usually  occurs  in  adults  as  the 
result  of  violence,  and  can  only  be  palliated  by  the  application  of  a 
bandage  or  truss  sufficiently  large  to  cover  the  opening  and  prevent 
the  escape  of  the  abdominal  contents,  except  in  the  variety  which  I 
discovered  and  was  the  first  to  describe  in  the  Pacific  Medical 
Journal,  as  peritoneal  hernia.  This  generally  occurs  near  the  linea 
alba,  and  ordinarily  above  the  umbilicus.  It  varies  in  size,  from  that 
of  a  pea  to  that  of  a  chestnut.  The  opening  being  too  small  to 
allow  anything  except  the  peritoneum  to  escape,  it  rarely  becomes 
larger  than  specified.  Having  been  repeatedly  consulted  in  such 
cases,  without  being  able  either  to  describe  the  character  of  the  dis- 
ease or  afford  relief,  I  determined  to  remain  no  longer  in  ignorance. 


196          LECTURES  ON  PRACTICAL  SURGERY. 

Assisted  by  Dr.  Wooster,  of  this  city,  the  tumor  was  exposed,  and 
consisted  entirely  of  peritoneum,  which  was  returned  by  the  use  of 
a  probe  into  the  abdomen,  through  an  opening  not  larger  than  a 
goosequill.  The  external  wound  was  closed,  a  compress  and  band- 
age applied,  and  in  two  weeks  the  patient  was  well,  being  entirely 
relieved  of  the  annoyance  it  produced.  I  have  since  operated  upon 
two  cases,  in  which  the  peritoneum  could  not  be  returned.  It  was 
removed  with  the  scissors,  and  the  patient  recovered  as  rapidly  as 
the  first  who  submitted  to  the  operation.  Other  varieties  of  hernia 
are  described  by  surgeons,  which,  however,  occur  so  rarely  that  they 
possess  but  little  interest. 

When  any  portion  of  the  abdominal  contents  passes  through  the 
ischiatic  notch,  it  is  called  hernia  dorsalis,  and  hernia  of  the  foramen 
ovale  or  hernia  of  the  perineum  when  in  these  localities.  When  an 
obscure  tumor  presents  in  any  portion  of  the  body,  and  when  doubt 
exists,  always  resort  to  the  exploring  needle,  and  be  guided  by  the 
result. 

After-treatmenL — Generally,  in  a  few  hours  after  the  stricture 
has  been  removed  and  the  hernia  reduced,  all  the  unpleasant  symp- 
toms disappear.  The  bowels  frequently  act  without  assistance,  and 
the  patient  speedily  recovers.  Should  this,  however,  fail  to  occur, 
you  must  recollect  that  the  strangulated  portion  of  the  intestine  is 
more  or  less  inflamed,  and  it  would  be  injudicious  to  administer  a 
cathartic  before  the  third  or  fourth  day,  and  then  an  enema  of  salt 
and  water  should  be  preferred,  and  if  that  fails,  a  small  dose  of 
castor-oil  or  citrate  of  magnesia  may  be  substituted. 

After  every  operation  of  this  character  there  is  danger  of  inflam- 
mation, consequently,  so  soon  as  the  operation  is  complete,  you  should 
always  administer  a  full  dose  of  some  preparation  of  opium,  and 
repeat  it  at  longer  or  shorter  intervals  according  to  the  effect.  The 
pain  must  be  relieved ;  if  it  is  violent,  and  the  stomach  is  irritable, 
either  apply  the  sulphate  of  morphia  endermically  or  hypodermically, 
or  throw  a  teaspoonful  of  the  tincture  of  opium  into  the  rectum. 
Should  inflammation  occur,  in  spite  of  these  precautions,  more  active 
means  should  be  employed.  Take  blood  from  the  arm,  or  apply 
leeches,  or  both,  as  may  be  necessary.  If  the  patient  be  young  and 
vigorous,  take  at  least  twenty  ounces  of  blood  from  the  arm.  After 
the  vein  is  opened,  have  the  head  elevated  and  allow  the  blood  to 
flow  until  syncope  is  threatened,  and  after  reaction  takes  place  and 


LECTURE    XV.  —  HERNIA. 


197 


the  difficulty  still  continues,  apply  as  many  leeches  as  the  condition  of 
the  patient  will  permit.  Fomentations  or  the  warm-water  dressing 
should  be  applied  so  soon  as  the  operation  is  completed,  and  con- 
tinued until  the  patient  is  convalescent. 

After  the  pain  has  been  relieved  by  the  remedies  indicated,  calomel 
and  opium  should  be  substituted,  in  doses  corresponding  with  the 
urgency  of  the  symptoms,  and  alternated  with  the  veratrum  viride  and 
tincture  of  aconite,  to  control  arterial  action,  until  the  specific  effect 
of  the  other  remedies  can  be  obtained.  In  peritonitis,  as  well  as  in 
all  internal  inflammations,  the  nourishment  should  be  small  in  quan- 
tity and  of  the  mildest  character,  such  as  arrowroot,  corn-meal  gruel, 
or  chicken-water.  A  solution  of  gum  arabic,  or  some  other  muci- 
laginous drink,  should  be  directed  in  order  to  quench  the  thirst, 
which  is  frequently  very  distressing. 

I  repeat,  do  not  give  a  cathartic  so  soon  as  the  hernia  is  reduced. 
Inflammation  of  the  serous  coat  always  paralyzes  to  a  greater  or  less 
extent  the  muscular,  and  if  you  force  down  the  contents  of  the  upper 
portion  of  the  canal,  instead  of  passing  through  they  will  accumu- 
late, increase  the  inflammation,  and  endanger  the  life  of  the  patient. 
Wait  three  or  four  days,  until  the  intestine  has  so  far  recovered  as 
to  act  upon  the  contents,  and  then  a  laxative  may  be  administered 
with  the  happiest  effect. 


L I  P»  R  A  K  Y 

OF 


198  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   XVI. 

GENTLEMEN  :  The  urinary  bladder  very  frequently  becomes  the 
seat  of,  or  receptacle  for,  concretions,  which  vary  in  size,  number, 
consistence,  color,  and  composition. 

Healthy  urine  always  holds  in  solution  substances  which  are  de- 
posited when  it  is  cold  and  at  rest,  which  may  under  certain  circum- 
stances cohere  and  form  what  is  called  a  urinary  calculus.  The 
deposits  present  an  opaque  floating  substance,  whitish  or  pale-yellow, 
near  the  bottom  of  the  vessel,  which  is  either  phosphate  of  lime  or 
the  triple  phosphate  of  magnesia  and  ammonia ;  or  they  may  adhere 
to  the  vessel  and  present  a  white  or  reddish  appearance,  and  are  com- 
posed usually  of  either  uric  acid  or  the  urate  of  ammonia.  The 
urine  may  also  hold  in  solution,  besides  the  substances  specified,  the 
oxalate  of  lime,  from  which  is  formed  the  most  irregular  and  painful 
variety  of  calculus.  All  that  is  necessary  for  their  production  under 
any  circumstances  is  a  nucleus.  A  clot  of  blood,  a  portion  of  mucus, 
a  needle,  the  extremity  of  a  gum  catheter,  or  any  other  foreign  sub- 
stance, if  free  in  the  bladder,  will  serve  as  well  for  that  purpose  as  a 
renal  calculus,  which  is  the  most  frequent  cause. 

Predisposing  Causes. — The  first  and  most  important  is  indiges- 
tion. When  the  stomach  and  liver  perform  their  functions  imper- 
fectly there  is  always  an  increase  of  uric  acid,  and  when  this  is 
abundant,  as  in  persons  who  suffer  from  gout,  a  small  calculus  will 
form  in  the  kidneys.  This,  after  passing  through  the  ureter  with 
great  difficulty,  and  if  not  speedily  expelled  by  the  bladder,  will  in 
a  short  time  become  a  urinary  calculus.  I  treated  a  case  some  years 
ago  in  this  city,  of  gravel,  complicated  with  gout,  and  the  patient 
after  a  very  unpleasant  night  collected  twenty-four  renal  calculi 
about  the  size  of  a  buckshot,  which  had  passed  during  that  time 
through  the  urethra ;  if  any  of  them  had  remained  he  would  soon 
have  experienced  the  symptoms  of  stone  in  the  bladder. 

Inflammation  of  the  mucous  membrane  of  that  organ  is  a  very 
fruitful  source  of  stone.  When  a  great  quantity  of  mucus  is  secreted, 


LECTURE  XVI.  —  VARIETIES  OF  STONE.         199 

should  it  be  too  tenacious  to  pass  through  the  urethra,  in  a  few  clays 
a  calcareous  deposit  will  be  made  upon  its  surface,  and  a  stone  pro- 
duced. I  have  found  it  necessary  to  remove  portions  of  gutta-percha 
catheters  from  the  bladder,  which  after  remaining  two  weeks  will  be 
found  incrusted  with  calcareous  matter,  and  produce  all  the  symp- 
toms of  stone  resulting  from  any  other  cause.  I  shall  always  recol- 
lect the  case  of  a  lady  upon  whom  I  operated  in  1835.  She,  in  con- 
sequence of  being  paralyzed,  found  it  necessary  to  have  a  catheter 
introduced  two  or  three  times  a  day  to  obtain  relief.  Soon  the  symp- 
toms of  stone  became  very  decided,  and,  when  removed,  in  the  centre 
was  found  a  cotton  thread  about  an  inch  in  length  which  had  been 
pushed  into  the  bladder  with  the  catheter. 

The  nucleus  is,  however,  almost  always  a  renal  calculus  or  gravel, 
which  forms  in  the  kidneys  in  consequence  of  derangement  of  the 
digestive  organs;  this,  after  reaching  the  bladder,  should  it  remain 
there  a  few  days,  will  become  too  large  to  pass  through  the  urethra. 
It  is  well  known  that  in  limestone  districts  of  country  this  disease 
is  more  common  than  elsewhere.  Professor  Dudley,  who  lived  in  a 
small  town  in  Kentucky,  it  is  said  operated  207  times;  but  if  he  had 
lived  either  in  the  South  or  in  California  he  would  not  even  with  his 
reputation  have  found  so  many  cases  of  that  character. 

Varieties  of  Stone. — There  is  contained  in  the  collection  which  I 
presented  to  the  College,  only  one  specimen  of  this  variety  of  stone, 
which  is  called  the  uric  acid  calculus.  It  is  generally  oval,  varies 
greatly  in  size,  and  may  present  either  a  smooth  surface  or  one  cov- 
ered with  small  projections.  It  is  usually  brown  when  first  re- 
moved, but  soon  presents  a  whitish  appearance,  and  is  distinctly 
lamellated.  It  is  described  as  being  very  common,  yet  in  this  State 
it  does  not  occur  so  frequently  as  other  varieties. 

This  calculus  is  composed  of  the  phosphate  of  lime;  it  is  small, 
very  smooth,  triangular  in  shape,  presents  a  light-brown  appearance, 
and  occurs  very  rarely.  It  was  removed  from  a  boy  in  this  city 
about  two  years  old,  and  he  made  a  rapid  and  satisfactory  recovery. 

This  immense  stone  is  composed  of  the  triple  phosphate  of  mag- 
nesia and  ammonia;  it  is  oval  in  shape,  presents  a  white  glistening 
appearance,  and  is  never  laminated,  and  as  you  will  observe,  in  this 
specimen  retains  its  original  unbroken  appearance. 

The  fusible  calculus,  composed  of  the  phosphate  of  lime  and  the 
triple  phosphate  of  magnesia  and  ammonia,  frequently,  as  you  will 


200  LECTURES    ON    PRACTICAL    SURGERY. 

see  by  examining  this  specimen,  acquires  great  magnitude;  they  are 
always  laminated,  white,  and  disintegrate  rapidly,  even  when  pro- 
tected, as  this  has  been,  from  atmospheric  influence.  A  portion  of  the 
external  layer  has  been  detached,  which  exposes  the  one  beneath. 
There  are  several  specimens  of  this  variety  in  the  collection,  and  in 
California  they  are  exceedingly  large,  in  consequence  of  the  great 
length  of  time,  they  are  usually  allowed  to  remain  in  the  bladder. 

This  differs  entirely  from  any  of  the  others  exhibited.  It  is  nearly 
round,  almost  black,  nearly  as  large  as  a  walnut,  and  the  surface  is 
exceedingly  irregular;  this  is  the  specimen  which  you  all  saw  re- 
moved from  a  young  man  in  the  hospital.  It  is  composed  of  the  oxa- 
late  of  lime,  and  from  its  shape  is  called  the  mulberry  calculus.  It 
is  rough,  exceedingly  hard,  and  could  not  be  tolerated  if  the  depres- 
sions were  not  filled  with  mucus,  which  is  secreted  very  abundantly 
by  the  inflamed  mucous  membrane  of  the  bladder.  Professor  Silli- 
man,  who  examined  it  during  his  visit  to  this  State,  considered  it  the 
largest  and  most  perfect  mulberry  calculus  he  had  ever  seen. 

This  variety  is  very  rare  and  always  small,  and  I  am  much  grati- 
fied to  be  able  to  exhibit  this  specimen  to  the  class.  It  is  called  the 
cystic  oxide  calculus,  and  was  removed  from  a  gentleman  from  Idaho 
about  a  year  since.  In  shape  it  is  irregular  and  yellow ;  it  is  very 
compact,  semi-transparent,  and  presents  a  glistening  appearance. 
These  calculi  were  analyzed  by  Professor  Price,  and  their  composi- 
tion ascertained.  You  cannot  always  determine  the  character  of  a 
stone  by  its  appearance,  and  it  is  not  very  important,  as  an  oppor- 
tunity to  make  an  examination  does  not  present  until  they  are  re- 
moved, and  consequently  a  knowledge  of  the  variety  would  not  in- 
fluence the  treatment. 

Symptoms. — I  will  endeavor  to  give  you  the  symptoms  which 
should  induce  you  to  suspect  the  existence  of  a  stone.  When  the 
patient  complains  of  constant  pain  or  uneasiness  in  the  region  of  the 
kidneys  and  at  the  extremity  of  the  penis,  with  a  frequent  inclination 
to  pass  urine,  in  which,  after  a  paroxysm,  small  fibrinous  clots  may 
be  detected,  particularly  if  accompanied  with  either  sickness  of  the 
stomach  or  vomiting,  you  should  suspect  the  existence  of  a  calculus 
in  the  kidneys,  and  if  after  these  symptoms  have  existed  some  time, 
he  is  attacked  with  excruciating  pain  extending  along  the  course  of 
the  ureter  of  either  side,  accompanied  with  retraction  of  the  testicle, 
which  continues  for  several  hours  without  even  being  mitigated  by 


LECTURE    XVI.  —  TREATMENT    OF    STOJJE.  201 

the  remedies  usually  employed  for  that  purpose,  you  may  feel  confi- 
dent that  gravel  has  passed  from  the  kidney  to  the  bladder.  If  after 
these  symptoms  have  subsided,  pain  and  difficulty  is  experienced  in 
passing  the  urine,  and  particularly  if  the  flow  is  sometimes  suddenly 
arrested  before  the  contents  of  the  bladder  have  been  expelled,  accom- 
panied with  an  increase  of  pain,  you  should  always  suspect  the  pres- 
ence of  a  stone.  The  only  way  in  which  you  can  positively  deter- 
mine it,  however,  is  to  introduce  a  sound  or  silver  catheter,  which 
should  be  preferred,  and  if,  the  bladder  being  partially  filled  with 
urine,  the  stone  cannot  be  felt,  allow  the  urine  to  escape,  and  then 
it  will  generally  be  brought  in  contact  with  the  extremity  of  the  in- 
strument, and  a  grating  sensation  will  be  imparted  to  the  fingers, 
which  can  seldom  be  mistaken.  The  prepuce  is  always  elongated, 
and  the  penis  is  generally  enlarged,  which  results  from  the  friction 
made  by  the  patient  to  alleviate  the  pain  experienced,  particularly 
during  a  paroxysm.  In  either  adults  or  children  always  use  a  silver 
catheter,  and  make  two  or  three  examinations  when  a  stone  is  sus- 
pected before  forming  a  diagnosis.  I  advise  this  course  because  the 
three  last  cases  upon  which  I  operated  were  treated  in  this  city  for 
several  months  for  either  cystitis  or  stricture,  without  the  existence 
of  stone  being  suspected.  These  cases  are  mentioned  to  prevent  you 
from  committing  a  similar  error. 

Treatment. — Before  performing  an  operation  for  stone  always  pre- 
pare the  patient  properly,  for  upon  that  your  success  will  greatly 
depend.  Nothing  will  alleviate  the  irritation  and  pain  resulting 
from  the  presence  of  a  stone  in  the  bladder  as  speedily  as  calomel. 
I  cannot  give  you  the  modus  operandi,  but  I  have  often  observed 
the  effect.  Before  operating  for  stone  I  always  prescribe  two  or 
three  five-grain  doses  of  calomel  every  alternate  night,  until  the 
local  irritation  is  greatly  diminished,  and  have  sometimes  relieved 
the  patient  so  much  that  he  would  consider  himself  cured,  and  refuse 
to  submit  to  the  operation  until  the  symptoms  returned.  The  food 
for  a  week  or  more  should  be  simple,  easily  digested,  and  so  moder- 
ate in  quantity  that  it  can  be  easily  and  readily  disposed  of  by  the 
stomach. 

Radical. — To  relieve  a  patient  of  stone  you  may  either  adopt 
such  means  as  will  promote  its  escape  entire,  break  it  into  particles 
small  enough  to  pass  through  the  urethra  with  the  urine,  or 
make  an  opening  sufficiently  large  to  enable  you  to  remove  it  with 


202  LECTURES    ON    PRACTICAL    SURGERY. 

forceps.  I  have  frequently  prevented  a  calculus  from  forming  in 
the  bladder  by  taking  the  precaution,  after  a  portion  of  gravel  has 
passed  through  the  ureter,  to  direct  the  patient  to  retain  his  urine 
until  the  bladder  is  considerably  distended,  and  then,  in  a  bent  posi- 
tion, to  expel  it  as  forcibly  as  possible.  In  this  way  the  gravel  will 
often  be  discharged,  while  if  neglected  it  may  in  a  few  days  become 
too  large  to  pass  through  the  urethra,  or  it  may  pass  from  the  blad- 
der and  lodge  in  the  membranous  portion  of  that  canal.  I  have 
operated  twice  upon  the  same  patient  within  a  year  to  remove  a 
stone  from  the  urethra.  The  wound  healed  readily  after  each 
operation,  and  the  canal  was  not  contracted.  Some  years  since  I 
removed  a  stone  that  had  been  in  the  urethra  thirteen  years,  and 
the  patient  had  been  treated  for  stricture.  The  stone  was  larger 
than  a  chestnut,  yet  the  urine  was  voided  without  much  difficulty ; 
the  wound  healed  in  two  weeks,  and  he  has  experienced  no  incon- 
venience from  the  dilatation  of  the  canal  that  must  have  existed  to 
accommodate  so  large  a  foreign  substance.  In  cases  of  this  charac- 
ter, except  when  they  are  accidental,  you  will  find  derangement  of 
the  digestive  organs,  particularly  of  the  stomach  and  liver,  with 
more  or  less  constipation,  which  should  be  corrected  in  order  to  pre- 
vent a  recurrence  of  the  difficulty. 

The  next  method  of  removing  a  stone  is  to  crush  it  so  effectually 
that  the  particles  will  pass  through  the  urethra.      To  Civiale,  of 


FIG.  57. 


Paris,  is  due  the  credit  of  directing  the  attention  of  the  profession 
to  this  subject,  as  well  as  of  having  been  the  first  to  perform  this 
operation  successfully.  The  first  instrument  he  used  for  that  pur- 
pose would  have  been  exceedingly  dangerous  in  less  skilful  hands, 
and  was  soon  abandoned.  Several  instruments  of  this  character 
called  " brise-pierre"  or  stone  breakers,  which  are  slightly  curved, 
strong,  and  well  adapted  to  that  use,  have  been  invented,  the  best  of 
which  is  represented  in  Fig.  57.  The  surgeons  who  were  most 
conspicuous  in  the  treatment  of  stone  by  this  method,  which  is 


LECTURE    XVI.  —  LITHOTRITY.  203 

lithotrity  or  lithotripsy,  are  Amussat,  Leroy,  Heurteloup,  and  Civi- 
ale. I  have  seen  Civiale  operate  frequently,  and  I  know  that  no 
man  possessed  more  manual  dexterity  or  was  better  acquainted  with 
the  diseases  of  the  urinary  organs.  During  my  stay  in  Paris  I  had 
access  to  both  the  Necker  and  Hotel  Dieu  Hospitals,  and  witnessed 
the  operations  of  both  Civiale  and  Dupuytren,  and  upon  comparing 
the  results  I  came  to  the  conclusion  that  except  in  the  hands  of 
specialists,  of  men  of  extraordinary  manual  dexterity  acquired  by 
experience,  the  knife  is  safer  than  the  ecraseur.  Lithotrity  is  not  ap- 
plicable to  children  or  boys.  The  parts  are  not  only  too  irritable, 
but  the  urethra  is  also  too  small  to  receive  an  instrument  sufficiently 
strong  for  the  purpose.  In  adults,  when  the  stone  is  small  and  there 
is  neither  stricture,  enlargement  of  the  prostate  gland,  nor  ulceration 
of  the  bladder,  this  operation  is  applicable.  Before  introducing  the 
instrument  calculated  to  break  or  crush  the  stone,  if  the  bladder  be 
empty,  some  tepid  water  should  be  injected  through  a  catheter  and 
retained  until  the  instrument  is  introduced.  The  patient  should  be 
placed  upon  the  back ;  when  the  extremity  of  the  instrument 
comes  in  contact  with  the  stone  the  blades  should  be  separated,  and 
when  it  is  within  their  grasp  sufficient  force  should  be  applied  to 
obtain  the  desired  result ;  should  the  first  operation  fail,  so  soon  as 
the  irritation  subsides,  which  sometimes  occurs  in  three  or  four  days, 
it  may  be  repeated.  When  the  stone  is  large  and  hard  this  treat- 
ment is  frequently  not  only  tedious  but  dangerous,  and  sometimes  it 
becomes  necessary  to  abandon  it  and  resort  to  the  knife. 

Lithotomy  consists  in  cutting  an  opening  sufficiently  large  to  en- 
able you  to  introduce  large  forceps  into  the  bladder  and  remove  the 
stone.  Different  methods  have  been  recommended  and  advocated. 
Frere  Jacques,  a  friar,  was  the  first  to  remove  a  stone  by  making  a 
free  incision.  After  having  frequently  witnessed  the  suffering  of 
the  unhappy  victims  of  this  disease,  and  being  a  man  of  strong  com- 
mon sense,  he  came  to  the  conclusion  that  as  he  could  feel  the  stone 
by  passing  his  fingers  into  the  rectum,  if  it  were  drawn  down  for- 
cibly against  the  perineum  it  might  be  removed  by  cutting  down 
so  as  to  divide  the  parts  that  intervened.  He  often  succeeded  by 
pursuing  that  course,  but  he  undoubtedly  frequently  wounded  parts 
that  should  have  been  avoided.  The  first  improvement  made  in 
this  operation  was  by  Cheselden.  He  recommended  what  is  still 
called  the  lateral  operation,  in  which  the  incision  extends  from  the 


204  LECTURES    ON    PRACTICAL    SURGERY. 

inferior  portion  of  the  scrotum  obliquely  downwards,  and  terminates 
between  the  anus  and  the  tuberosity  of  the  ischium  on  the  left  side. 
The  rectum  in  this  operation  is  on  the  left  side  of  the  incision,  and 
the  pudic  artery  on  the  right,  which  are  the  most  important  parts  in 
the  vicinity  of  the  wound.  Before  performing  any  operation  of  this 
character,  the  rectum  should  be  emptied  by  an  enema,  and  then  you 
should  examine  its  size,  and  make  the  incision  so  that  it  will  not  be 
5g  endangered.  After  reaching  the  staff,  and 

before  the  urethra  has  been  divided,  should 
you  find  that  the  rectum  has  been  wounded, 
the  operation  should  not  be  completed,  but 
that  for  fistula  in  ano  substituted,  and  when 
the  wound  heals,  the  operation  for  stone  can 
be  performed  with  as  good  a  prospect  of  suc- 
cess as  if  the  accident  had  not  occurred. 

Frere  Come  invented  what  he  called  the 
lithotome  cache",  with  one  concealed  blade, 
with  which  he  performed  the  lateral  operation, 
which  I  think  is  superior  to  the  instruments 
now  employed  for  that  purpose.  But  for  the 
instrument  exhibited,  with  two  concealed 
blades,  called  the  double  lithotome  cach£,  we 
are  indebted  to  Dupuytren,  the  greatest  genius 
of  his  age,  and  with  it  he  performed  the  bilat- 
eral operation,  which  I  think  should  always  be 
preferred.  In  expressing  this  opinion,  I  am 
aware  that  I  differ  with  many  able  surgeons, 
yet  I  think  that  I  can  convince  every  mem- 
ber of  this  class  that  the  bilateral  is  more 
easily  performed  and  more  successful  than 
any  other  that  has  been  practiced.  Before 
commencing  the  operation,  pass  the  grooved 
staff  into  the  bladder,  for  the  purpose  of  giving 
your  assistants  the  privilege  of  feeling  the 
stone,  and  deciding  upon  the  necessity  of  an 
operation.  The  table  should  be  high,  strong, 
and  about  three  feet  in  width.  It  should  be 

covered  by  a  blanket,  protected  by  oiled-cloth,  over  which  a  cotton 
sheet  may  be  thrown.     The  head  should  be  supported  by  two  pil- 


LECTURE    XVI.  —  BILATERAL    LITHOTOMY.  205 

lows,  and  the  hands  and  feet  secured  firmly  together  by  a  roller 
bandage.  The  perineum  should  project  beyond  the  edge  of  the 
table,  and  a  tub  should  be  placed  so  as  to  receive  the  blood  and  urine 
which  must  necessarily  escape  when  the  incisions  are  made.  When 
the  grooved  staff  is  introduced,  it  should  be  held  by  an  assistant  on 
the  left  side,  in  order  that  he  may  use  the  right  hand.  Should  the 
urethra  be  small  or  strictured,  a  small  staff  may  be  substituted  for 
the  size  usually  employed,  which  I  found  necessary  a  few  days  since, 
in  an  old  gentleman  from  Mexico,  whose  urethra  had  been  lacerated 
by  a  surgeon  of  Hermesilla  in  endeavoring  to  pass  a  catheter  into  the 
bladder. 

After  the  necessary  preparation  has  been  made,  in  the  bilateral 
operation,  make  a  semilunar  incision  three-fourths  of  an  inch  above 
the  anus,  which  should  extend  from  the  tuberosity  of  the  ischium  on 
the  right,  to  the  same  point  on  the  opposite  side.  The  first  incision 
should  divide  the  skin  and  superficial  fascia,  and  then,  with  the 
finger  of  the  left  hand  in  the  rectum,  the  wound  should  be  deepened, 
so  as  to  divide  the  transversalis  muscle  and  deepseated  fascia,  and 
probably  the  artery,  although  that  may  escape.  The  second  incision 
should  be  sufficiently  deep  to  expose  the  membranous  portion  of  the 
urethra,  so  as  to  avoid  the  artery  of  the  bulb,  which  might  give  rise 
to  troublesome  haemorrhage.  Before  dividing  the  urethra,  one  finger 
being  in  the  rectum,  the  forefinger  of  the  right  hand  should  be  passed 
into  the  wound,  so  as  to  determine  positively  that  the  rectum  has  not 
been  wounded,  and  then  the  blade  of  the  scalpel  should  be  turned 
upwards,  and  the  urethra  divided  so  as  to  expose  the  groove  in  the 
staff.  When  reached,  it  can  be  easily  ascertained  by  the  sensation 
imparted  to  the  fingers  with  which  the  knife  is  held.  The  beak  of 
the  lithotome  should  then  be  placed  in  the  groove  of  the  staff,  and 
passed  into  the  bladder,  with  the  curved  side  towards  the  rectum. 
The  position  of  the  lithotome  should  then  be  reversed,  and  the  staff 
removed.  When  elevated,  so  that  the  back  rests  against  the  pubes, 
the  blades  should  be  opened,  and  the  instrument  drawn  out  horizon- 
tally, so  as  to  avoid  wounding  the  rectum. 

With  this  instrument  I  have  operated  thirty-seven  times,  and  have 
never  had,  except  in  two  cases,  a  troublesome  haemorrhage.  The 
first  occurred  in  a  boy  twelve  years  old,  and  the  second  patient  was 
a  man  aged  sixty-six  years,  who  was  exceedingly  emaciated,  and 
upon  whom  I  operated  only  three  weeks  ago.  When  placed  upon 


206  LECTURES    ON    PRACTICAL    SURGERY. 

the  table,  his  pulse,  being  counted  by  Professor  Morse,  was  one  hun- 
dred and  sixty-eight  in  a  minute.  Two  calculi  were  removed,  and 
although  the  haemorrhage  was  considerable,  it  was  speedily  arrested 
by  passing  a  large  gum  catheter  into  the  bladder,  and  plugging  the 
wound  with  lint.  From  the  result  in  these  cases,  I  believe,  even 
when  there  is  no  haemorrhage,  it  would  be  better  to  pass  a  gum 
catheter  into  the  bladder,  and  fill  the  opening  made  by  the  scalpel 
with  lint.  It  not  only  prevents  haemorrhage,  but  also  infiltration  of 
urine,  which  is  the  greatest  danger  to  be  apprehended  from  the 
operation. 

In  the  lateral  operation  the  preparation  should  be  the  same.  The 
external  incision  should  extend  from  the  posterior  part  of  the  scro- 
tum to  the  centre  of  a  line  running  from  the  anus  to  the  tuberosity 
of  the  ischium.  The  same  precautions  are  necessary  in  order  to  avoid 
the  rectum,  and  when  the  membranous  portion  of  the  urethra  has 
been  opened,  and  the  staff  exposed,  the  neck  of  the  bladder  may  be 
divided  either  with  a  probe-pointed  bistoury,  a  long-handled  scalpel, 
or  the  gorget,  which  was  the  instrument  Professor  Dudley  always 
used.  In  this  operation,  whatever  instrument  is  employed,  the  in- 
cision is  confined  to  the  left  side  of  the  prostate  gland,  and  cannot 
without  danger  be  extended.  If  the  gorget  be  used,  the  beak  should 
be  placed  in  the  groove  of  the  staff,  and  then  passed  horizontally 
into  the  bladder.  If  a  bistoury  or  scalpel  be  preferred,  they  should 
follow  the  groove  until  they  have  passed  into  the  bladder,  and  an 
incision  made  as  extensive  as  may  be  necessary  to  remove  the  stone. 
I  performed  the  lateral  operation  three  times  with  the  gorget  suc- 
cessfully, yet  I  prefer  the  bilateral  method,  and  you  may  ask  why? 
I  prefer  it  because  the  greatest  danger  in  the  operation  of  lithotomy 
arises  from  the  division  of  the  prostatic  fascia.  The  prostate  gland 
in  the  adult  is  usually  twenty-one  lines  in  diameter,  and  when  the 
fascia  by  which  it  is  surrounded  is  not  divided,  there  is  very  little 
danger  of  infiltration  of  urine.  In  the  lateral,  if  the  stone  be  large 
it  would  be  impossible  to  remove  it  without  making  an  incision 
more  than  ten  lines  in  length,  which  would  expose  the  patient  to  a 
complication  which  is  almost  always  fatal.  In  the  bilateral  opera- 
tion you  may  cut  fifteen  or  even  eighteen  Hues  with  perfect  safety, 
and  through  an  opening  of  that  size  you  can  remove  such  stones  as 
I  have  exhibited  without  difficulty,  because  besides  the  incision  you 
have  the  benefit  resulting  from  the  elasticity  of  the  parts.  In  chil- 


LECTURE    XVI.  —  SUPRA-PUBEC    LITHOTOMY.  207 

dren  the  instrument  should  be  gauged  so  as  to  cut  only  ten  or 
twelve  lines,  which  makes  an  opening  large  enough  to  admit  the 
finger,  and  then  with  common  dressing  forceps  you  can  easily  re- 
move the  calculus.  I  have  never  lost  a  child  after  an  operation  for 
stone,  and  have  upon  them  always  performed  the  bilateral  operation. 
Of  the  thirty-seven  operations  performed  with  the  same  instrument 
only  two  were  lost,  one  from  inflammation  of  the  bladder,  the 
other  from  pyaemia  on  the  twenty -second  day,  and  when  the  patient 
was  considered  convalescent,  the  urine  having  passed  through  the 
urethra  for  five  or  six  days  before  the  symptoms  of  pyaBmia  were  de- 
cided. 

The  next  operation  of  which  I  will  speak  is  the  suprapubic. 
The  incision  is  made  in  the  linea  alba,  above  the  pubis,  but  below 
the  peritoneum.  Civiale  occasionally  performed  it  when  the  stone 
was  very  large,  but  I  have  never  met  with  one  so  large  that  it  could 
not  readily  be  removed  by  the  bilateral  operation.  Should  you, 
however,  after  a  careful  investigation,  arrive  at  the  conclusion  that  its 
removal  would  lacerate  the  parts  implicated  extensively,  then  the 
suprapubic  operation  would  be  justifiable.  The  bladder  should  be 
filled  with  tepid  water  so  as  not  to  endanger  the  peritoneum.  The 
incision  should  be  three  or  four  inches  in  length,  according  to  the 
size  of  the  stone,  and  when  the  bladder  is  exposed  an  incision  should 
be  made,  and  the  stone  removed  with  the  ordinary  forceps.  A  cathe- 
ter should  be  kept  constantly  in  the  bladder,  and  the  patient  con- 
fined on  his  back  until  the  danger  of  infiltration  has  passed,  which 
under  such  circumstances  is  always  fatal.  Consequently  I  would 
advise  you  always  to  perform  the  bilateral  operation,  and  if  the  stone 
be  large,  crush  it  and  remove  the  fragments.  The  forceps  which  I 
exhibit  would  crush  any  calculus,  and  the  operation  would  be  less 
dangerous  than  that  usually  performed  above  the  pubis,  and  much 
less  difficult.  Sanson,  who  was  one  of  the  surgeons  of  the  Hotel 
Dieu  in  Paris,  in  1833,  removed  calculi  through  the  rectum.  The 
operation  was  easily  performed,  but  as  in  almost  every  case  it  was 
followed  by  a  vesico-rectal  fistula,  which  is  always  incurable,  I  think 
this  method  should  never  be  selected.  Many  able  surgeons  both 
recommend  and  practice  the  lateral  operation,  but  I  think  it  is  be- 
cause they  have  never  performed  the  bilateral.  With  the  double 
lithotome  cache  the  extent  of  the  incision  can  be  positively  deter- 
mined. The  incision  is  made  much  more  easily  than  with  the  gorget, 


208  LECTURES    ON    PRACTICAL    SURGERY. 

because  the  blades  are  not  expanded  until  it  is  withdrawn  from  the 
bladder.  The  first  operation  I  performed  with  the  gorget  the  handle 
of  the  instrument  was  not  sufficiently  depressed,  so  that  its  edge 
came  in  contact  with  the  staff,  and  some  difficulty  was  experienced 
in  its  introduction.  If  the  lithotorne  be  used  it  passes  readily  into 
the  bladder,  when  the  staff  should  be  removed,  and  if  possible  the 
extremity  of  the  instrument  should  rest  upon  the  stone.  The  posi- 
tion of  the  instrument  should  then  be  reversed,  and  the  convex  side 
turned  towards  and  brought  in  contact  with  the  pubes.  The  blades 
should  then  be  expanded  by  pressing  firmly  upon  the  spring,  and 
the  incision  made  by  drawing  the  instrument  horizontally  outwards. 
This  subject  will  be  continued  in  the  next  lecture. 


LECTURE    XVII. — LITHOTOMY.  209 


LECTURE  XVII. 

GENTLEMEN  :  Having  described  the  different  varieties  of  stone, 
and  the  operations  by  which  they  can  be  removed,  I  will  now  pro- 
ceed to  the  consequences  that  may  arise  from  such  operations.  No 
matter  how  skilfully  the  knife  may  be  used,  you  must  not  expect 
that  every  patient  will  make  a  safe  and  rapid  recovery.  If  that 
were  the  case  there  would  be  no  pursuit  so  delightful  as  the  practice 
of  surgery. 

The  first  to  which  I  will  refer  is  collapse,  by  which  you  should 
understand  that  a  patient  will  sometimes  become  suddenly  and  un- 
expectedly prostrate.  Under  such  circumstances  the  pulse  is  scarcely 
perceptible,  the  breathing  is  labored,  the  extremities  are  cold,  and 
it  is  difficult  if  not  impossible  to  produce  reaction.  Such  cases  have 
occurred  in  this  as  well  as  in  other  surgical  operations,  but  as  long 
as  I  have  been  a  member  of  the  profession  I  have  never  had  a  patient 
either  to  die  on  the  table,  or  sooner  than  five  days  after  being  oper- 
ated upon.  I  have  always  thought  that  it  is  an  evidence  of  bad 
surgery.  It  indicates  either  that  too  much  blood  has  been  lost,  that 
the  patient  has  been  subjected  to  too  great  or  to  unnecessarily  pro- 
tracted pain,  or  that  he  was  not  in  a  proper  condition  to  undergo  an 
operation.  Before  the  discovery  of  chloroform  I  always  operated  as 
rapidly  as  possible,  and  even  since  its  discovery  I  can  find  no  reason 
that  will  justify  delay.  The  parts  being  at  rest,  and  no  resistance 
being  offered,  every  operation  should  be  performed  with  as  much 
expedition  as  is  compatible  with  safety.  You  have  all  seen  the 
operation  of  lithotomy  performed  in  fifty  seconds;  it  should  never 
occupy  more  than  four  minutes,  and  unless  the  opening  made  be  too 
small,  and  great  violence  be  offered  the  parts  in  the  vicinity,  but 
little  danger  need  be  apprehended.  When  prostration  does  occur, 
you  should  apply  heat  externally,  as  by  bottles  filled  with  hot  water, 
and  administer  stimulants  as  rapidly  as  the  condition  of  the  patient 
would  appear  to  indicate. 

Hcemorrhage. — The  next  and  a  much  more  frequent  difficulty  is 
hemorrhage.  In  the  forty  operations  which  I  have  performed,  it 

14 


210          LECTURES  ON  PRACTICAL  SURGERY. 

occurred  twice.  The  first  time  was  in  a  boy  twelve  years  old,  and 
the  second  in  an  old  man  of  sixty-six  years.  In  both  cases  the 
vessel  was  deepseated,  and  the  haemorrhage  could  only  be  arrested 
by  pressure,  which  was  easily  made  by  passing  a  straight  silver  or 
gum  catheter  into  the  bladder,  and  plugging  up  the  wound  carefully 
around  the  catheter  with  dry  lint,  from  the  prostate  gland  to  the  in- 
tegument. Both  the  catheter  and  lint  should  be  secured  by  a  well- 
adjusted  T-bandage.  In  such  cases  leave  nothing  to  chance;  plug 
up  the  wound  yourself,  because  you  are  more  interested  than  an  as- 
sistant, by  reason  of  the  responsibility  devolving  upon  you.  The  lint 
is  usually  detached  from  the  surface  of  the  wound  in  five  or  six  days, 
and  then  the  catheter  may  be  removed  with  safety.  The  haemor- 
rhage which  might  result  from  a  wound  of  any  vessel  in  that  vicinity 
may  be  arrested  by  pressure,  except  from  the  pudic  artery,  which  is 
only  endangered  in  the  lateral  operation.  That  vessel  can  be  se- 
cured by  strong  spring  forceps,  and  by  allowing  them  to  remain  a  few 
days  a  fatal  haemorrhage  may  be  prevented.  I  pursued  that  course 
in  a  case  in  which  the  inferior  thyroid  was  wounded,  with  the  most 
satisfactory  result.  Haemorrhage  is  always  an  unpleasant  occurrence 
after  any  operation,  and  you  should  take  every  precaution  to  pre- 
vent it. 

Infiltration  of  Urine. — This  is  the  most  serious  consequence  of  the 
operation  for  stone.  I  have  never  lost  a  case  from  that  cause,  but  it 
does  occasionally  occur,  and  I  am  satisfied  more  frequently  in  the 
lateral  than  bilateral  operations,  because  if  the  stone  be  large,  in  the 
former  it  frequently  becomes  necessary  to  divide  or  tear  the  prostatic 
fascia.  In  this  case  infiltration  is  exceedingly  liable  to  occur,  and 
when  it  does  it  is  almost  always  fatal. 

Inflammation. — After  every  operation  of  this  character  inflamma- 
tion may  be  set  up.  Of  the  forty  patients  operated  upon  by  me,  one 
died  of  cystitis  on  the  seventh  day,  and  another  in  about  three 
weeks,  of  pyaemia,  which  as  you  know  is  one  of  the  consequences  of 
inflammation.  You  may  have  cystitis  alone,  or  it  may  extend  to  the 
peritoneum,  and  be  accompanied  with  all  the  symptoms  of  that  fatal 
difficulty.  The  patient  who  died  of  cystitis  was  sixty -six  years  old, 
and  very  feeble  in  consequence  of  the  irritation  produced  by  the 
stone,  and  of  alburainuria,  from  which  he  had  suffered  for  several 
years.  The  largest  stone  in  our  collection  was  taken  from  him.  It 
is  so  large  that  even  with  an  incision  of  eighteen  lines  it  was  re- 


LECTURE    XVII.  —  LITHOTOMY.  211 

moved  with  great  difficulty.  The  operation  was  only  performed  to 
gratify  his  friends,  and  give  him  the  only  chance  which  remained  for 
life.  When  inflammation  supervenes  it  should  be  treated  according 
to  the  indications.  If  the  patient  be  young,  apply  leeches  and  fo- 
mentations, give  calomel  and  opium,  and  relieve  the  pain  by  laud- 
anum injections,  which  will  act  more  speedily  than  opiates  taken  into 
the  stomach,  and  can  be  resorted  to  when  that  organ  is  too  irritable  to 
retain  any  medicine.  Mucilaginous  drinks  may  also  produce  a  good 
effect,  but  I  rely  chiefly  upon  the  preparations  of  opium. 

Recto-vesical  fistula  may  result  from  the  operation  of  lithotomy. 
It  was  in  order  to  avoid  this  that  I  cautioned  you  so  particularly 
to  ascertain,  before  dividing  the  urethra,  whether  the  rectum  was 
wounded,  and  if  even  the  slightest  wound  be  detected,  the  sphincter 
ani  should  be  divided  and  the  case  treated  as  one  of  fistula  in  ano. 
There  is  nothing  so  unpleasant  as  a  urinary  fistula  of  this  character. 
It  is  incurable,  and  renders  the  subject,  no  matter  how  much  atten- 
tion he  may  pay  to  cleanliness,  an  object  of  disgust.  On  that  account, 
I  object  to  the  operation  practiced  by  Sanson  at  the  Hotel  Dieu. 
He  operated  through  the  rectum,  and  his  patients  always  suffered 
from  this  loathsome  infirmity. 

Females  occasionally  suffer  from  urinary  calculi.  The  first  oper- 
ation I  performed,  after  returning  from  Europe,  was  upon  a  female 
who  had  been  paralyzed  for  several  months,  with  retention  of  urine. 
Her  servant,  in  passing  a  female  catheter,  pushed  a  coarse  cotton 
thread  into  the  bladder,  which  served  as  a  nucleus  for  an  immense 
stone.  Although  the  general  health  of  the  patient  was  greatly  im-' 
paired,  besides  the  existence  of  paralysis,  the  urethra  was  divided 
bilaterally  with  the  lithotome,  and  a  stone  the  size  of  a  turkey's  egg 
removed  ;  the  patient  made  a  rapid  recovery.  This  operation  in  the 
female  is  exceedingly  simple,  but  still  I  would  not  recommend  it, 
except  in  such  a  case  as  I  have  described.  The  operation  of  lithot- 
rity,  when  the  stone  is  large,  and  the  bladder  can  expel  the  frag- 
ments, should  be  preferred,  and,  if  it  be  small,  the  urethra  should 
be  dilated  with  sponge  tents  or  the  forceps  sufficiently  to  admit  the 
dressing  forceps  and  to  allow  the  stone  to  be  extracted.  There  is 
much  less  danger  in  the  operation  of  lithotrity  when  performed  on 
females,  because  the  instrument  is  more  easily  introduced.  But  little 
difficulty  is  experienced  either  in  seizing  the  stone  or  in  removing 
the  fragments  after  it  has  been  crushed.  The  subsequent  treatment 


212  LECTURES    ON    PRACTICAL    SURGERY 

should  not  differ  from  that  which  is  recommended  in  similar  oper- 
ations upon  the  other  sex. 

Retention  of  Urine. — Females  sometimes  suffer  from  retention  of 
urine,  but  not  very  frequently.  It  may  result  from  overdistension ; 
in  other  words,  whenever  the  bladder  is  excessively  distended  it  loses 
its  contractile  power,  and  the  use  of  the  catheter  becomes  necessary 
to  give  relief.  I  have  met  with  cases  of  this  character,  where  females 
are  so  situated  that  they  cannot  attend  to  their  wants  until  this  con- 
dition exists,  and  then  they  find  it  impossible.  It  is  generally  not 
only  necessary  to  pass  a  catheter,  but  also  to  repeat  the  operation 
three  or  four  times  a  day,  until  the  function  of  the  organ  is  restored. 
When  the  occasional  use  of  the  instrument  is  not  sufficient,  a  male 
gum  catheter  should  be  introduced,  and  the  urine  allowed  to  flow  off 
constantly  until  the  difficulty  disappears. 

Retention  of  urine  sometimes  results  from  the  pressure  exerted 
by  the  gravid  uterus.  In  such  cases  the  urine  generally  passes 
readily  when  the  patient  is  on  the  back.  It  is,  however,  an  exceed- 
ingly unpleasant  symptom,  whether  it  appears  at  the  commencement 
or  at  a  more  advanced  period  of  gestation.  The  same  difficulty  may 
result  from  retroversion  of  the  uterus,  which  can  only  be  relieved 
by  passing  the  finger  into  the  rectum,  in  order  to  change  its  position, 
and  when  the  womb  is  restored  to  its  proper  position,  it  may  some- 
times become  necessary  to  introduce  a  pessary  to  prevent  a  recur- 
rence, although  I  think  that  they  are  only  admissible  in  such  cases. 

Incontinence  of  Urine. — Incontinence  of  urine  is  more  common 
than  retention.  It  may  occur  in  either  sex,  and  is  an  exceedingly 
unpleasant  infirmity.  Children  from  eight  to  twelve  years  of  age 
are  unable  to  retain  the  urine  at  night,  and  are  frequently  punished 
by  their  parents,  with  the  expectation  that  it  can  in  that  way  be  pre- 
vented. The  best  remedy  I  have  ever  prescribed,  is  a  combination  of 
tinct.  lyttse  and  tinct.  nucis  vomicse  with  simple  syrup,  exhibited  in 
five-drop  doses,  three  times  daily.  The  muriated  tinct.  of  iron,  when 
anaemia  exists,  is  sometimes  successful  in  removing  the  inability, 
although  in  a  majority  of  cases  the  tinct.  lyttae  and  nucis  vomicse 
will  more  certainly  afford  relief.  By  producing  irritation  of  the 
neck  of  the  bladder,  the  sensibility  is  so  much  increased  that  the 
patients  become  conscious  of  the  call  to  pass  the  urine.  When  in- 
ternal remedies  fail  in  male  children,  a  strip  of  gum-elastic  should 
be  placed  around  the  penis  when  the  child  retires,  sufficiently  tight 


LECTURE    XVII.  —  GONORRHC3A.  213 

to  prevent  the  possibility  of  such  an  occurrence  without  its  removal. 
By  adopting  this  treatment  you  can  frequently  cure  cases  that  have 
resisted  internal  treatment  in  a  very  short  time.  It  destroys  the 
habit,  and  seems  to  increase  or  restore  the  natural  sensibility  of  the 
organs.  I  have  recently  relieved  a  very  interesting  boy,  twelve  years 
old,  of  this  infirmity,  after  every  possible  method  of  internal  treat- 
ment had  failed. 

Gonorrhoea. — In  consequence  of  many  of  the  diseases  of  the  uri- 
nary organs  having  their  origin  in  gonorrhoea,  I  will  endeavor  to 
render  you  familiar  with  that  before  proceeding  with  their  consid- 
eration. Gonorrhoea  is  an  inflammation  of  the  urethra,  accompanied 
with  a  discharge,  which  generally  presents  a  thick  yellowish  appear- 
ance, although  it  may  be  either  whitish  or  green,  according  to  the 
mildness  or  violence  of  the  inflammation.  The  discharge  is  not  very 
unlike  pus  both  in  color  and  consistence ;  it  always  results  from  im- 
pure connection,  and  makes  its  appearance  usually  in  from  one  to 
four  days.  The  time  depends  upon  the  virulence  of  the  discharge 
and  the  susceptibility  of  the  subj  ect.  It  is  called  by  the  French  chaude 
pisse,  which  expresses  one  of  the  most  common  and  distressing  symp- 
toms of  the  disease,  and  one  which  usually  precedes  the  appearance 
of  the  discharge;  at  least  it  is  generally  felt  before  the  other  is 
observed.  When  the  disease  is  either  neglected  or  not  properly 
treated,  another  very  painful  and  annoying  symptom,  called  chordee, 
frequently  occurs  several  days  after  the  discharge,  and  depends  upon 
the  thickening  and  induration  of  the  urethra  produced  by  the  in- 
flammation, which  diminishes  or  destroys  the  elasticity  of  the  urethral 
canal.  Sometimes  when  the  urethra  is  excessively  inflamed,  a  lacer- 
ation of  the  mucous  membrane  takes  place  during  an  erection,  which 
may  be  followed  by  hemorrhage  so  profuse  as  to  afford  temporary 
relief.  You  may  all  have  been  led  to  think  that  you  can  cure  any 
case  of  gonorrhoea,  and  that  it  is  exceedingly  simple,  both  in  charac- 
ter and  treatment.  I,  however,  after  long  experience,  beg  leave  to 
differ  with  you.  I  think  that  under  the  circumstances  in  which 
most  of  such  patients  are  placed,  it  is  one  of  the  most  difficult  dis- 
eases to  cure  that  you  will  be  required  to  treat.  Should  the  patient 
be  in  a  hospital,  where  his  diet,  exercise,  and  medical  treatment  can 
be  properly  regulated  and  enforced,  you  will  often  have  no  difficulty. 
Exercise  should  be  prohibited.  You  order  a  saline  cathartic,  muci- 
laginous drinks,  the  application  of  cold  water  externally,  with  low 


214  LECTURES    ON    PRACTICAL    SURGERY. 

diet  until  the  acute  symptoms  disappear;  then  you  can  resort  to  the 
curative  treatment  with  a  certainty  of  success.  Should  you  expect 
to  cure  this  disease  in  one  or  two  weeks  in  a  laboring  man,  who  is 
obliged  to  eat  heartily  to  sustain  his  strength,  you  will  almost  always 
be  disappointed.  You  must  treat  him  with  the  ordinary  remedies, 
which  under  such  circumstances  fail  to  produce  their  usual  effect. 
There  are  only  two  articles  of  the  Materia  Medica  which  I  have 
found,  when  administered  internally,  to  exert  a  specific  influence  over 
this  disease,  and  they  are  balsam  of  copaiba  and  cubebs.  The  best 
way  to  give  the  former  is  in  the  shape  of  capsules,  and  the  latter 
may  be  given  in  powder,  tincture,  or  in  an  electuary  in  combination 
with  conserve  of  roses,  or  something  equally  agreeable.  The  greatest 
objection  to  the  use  of  copaiba  is  the  unpleasant  taste,  which  is  re- 
moved by  enveloping  it  in  such  a  manner  that  it  will  reach  the 
stomach  without  offending  either  the  sense  of  taste  or  smell.  Six  of 
Planten's  capsules  in  twenty-four  hours  are  as  many  as  can  usually 
be  taken  without  either  producing  sickness  of  the  stomach  or  acting 
too  freely  upon  the  bowels.  Of  the  powdered  cubebs  I  usually 
direct  one  teaspoonfnl  three  or  four  times  a  day  in  water,  or  a  tea- 
spoonful  of  the  tincture  as  frequently  repeated,  when  the  powder  is 
offensive  to  the  stomach.  By  the  use  of  either  of  the  articles  men- 
tioned, in  four  or  five  days  the  discharge  usually  diminishes  in  quan- 
tity and  changes  in  appearance ;  then  the  following  injection  should 
be  prescribed,  not  only  to  arrest  the  discharge,  but  to  prevent  its 
recurrence : 

R.— Zinci  Sulph. gr.  xvi. 

Tinct.  Opii, ^iv. 

Aqua  Font.,      .         .         .         .  .  ^viiss. 

M.  Sig.  Inject  three  times  a  day. 

Formerly  I  used  injections  much  stronger  than  the  one  recom- 
mended, but  they  were  abandoned  because  the  discharge  was  some- 
times checked  too  suddenly,  producing  consequences  more  serious 
than  the  one  under  treatment.  The  injection  should  be  repeated 
two  or  three  times  a  day;  throw  it  well  into  the  urethra,  have  it  re- 
tained from  two  to  five  minutes,  and  continued,  with  the  internal 
treatment,  at  least  ten  days  after  the  discharge  ceases,  in  order  to  pre- 
vent a  return.  The  urine  should  be  passed  a  short  time  before  the 
injection  is.  used,  so  as  to  expose  the  mucous  membrane  to  the  action 


LECTURE    XVII.  —  GONORRHOEA.  215 

of  the  remedy,  and  prevent  the  discharge  being  carried  back,  should 
the  injection  pass  beyond  the  point  diseased.  Should  a  change  be 
considered  advisable,  the  acetate  of  lead  or  zinc  in  the  same  strength 
may  be  substituted,  as  well  as  the  chloride  of  zinc,  one  grain  to  the 
ounce  of  water,  which  is  by  some  physicians  considered  superior  to 
any  other  remedy  of  this  character.  I  have  found  a  solution  of  the 
perchloride  of  iron,  one  drachm  to  eight  ounces  of  water,  exceedingly 
valuable  when  used  only  twice  a  day,  and  particularly  in  cases  in 
which  a  predisposition  to  orchitis  is  decided,  which  sometimes  renders 
the  treatment  of  gonorrhoea  very  difficult. 

A  solution  of  the  nitrate  of  silver,  from  ten  to  twenty  grains  to  the 
ounce  of  water,  was  in  fashion  some  years  since  to  effect  what  was 
called  the  abortive  treatment.  The  solution  was  injected  two  or 
three  times  a  day,  until  violent  inflammation  of  the  urethra  was  pro- 
duced, and  then  a  milder  treatment  substituted.  This  treatment  is 
only  justifiable  when  a  domestic  difficulty  can  be  avoided  by  its 
adoption.  In  all  other  cases  I  am  confident  that  whoever  has  seen 
the  bad  consequences  that  follow  as  frequently  as  I  have,  would 
never  resort  to  it  as  a  general  practice.  As  it  sometimes  produces 
a  permanent  induration  and  contraction  of  the  urethra,  other  astrin- 
gent injections  are  sometimes  employed,  such  as  a  weak  solution  of 
the  sulphate  of  copper  or  iron,  which  I  cannot  recommend,  although, 
under  certain  circumstances,  I  think  I  have  derived  considerable 
benefit  from  the  use  of  a  five-grain  solution  of  alum  to  the  ounce  of 
water,  particularly  after  the  inflammatory  symptoms  have  subsided, 
when  in  cases  of  idiosyncrasy  the  copaiba  produces  a  cutaneous 
eruption.  Should  cubebs  be  obnoxious  to  the  patient,  twenty  drops 
of  the  solution  of  the  perchloride  of  iron  three  times  a  day  should  be 
substituted.  In  the  treatment  of  gonorrhoea,  particularly  in  office 
patients,  unpleasant  symptoms  frequently  occur.  Whether  an  injec- 
tion be  used  or  not,  so  soon  as  the  discharge  either  diminishes  or 
ceases  entirely,  great  irritability  of  the  prostatic  portion  of  the  urethra 
takes  place,  indicated  by  a  frequent  inclination  to  pass  the  urine,  ac- 
companied with  considerable  pain,  which  is  exceedingly  annoying, 
and  can  only  be  relieved  by  restoring  the  discharge,  and  if  that  can- 
not be  effected  in  a  few  days,  the  irritation  will  extend  to  one  or  both 
of  the  testicles,  and  orchitis  will  be  the  result.  In  such  cases  the 
specific  treatment  should  be  abandoned,  a  warm  bath  should  be 


216  LECTURES    ON    PRACTICAL    SURGERY. 

recommended,  with  mucilaginous  drinks,  and  the  following  mixture 
given  internally : 

R.— Tinct.  Pip.  Cubebae, Sjiij. 

Vin.  Colch.  Seminis,        .......     ^j. 

Morph.  Sulph.,         ........     gr.  iv. 

M.  Sig.  Take  one  teaspoonful  four  times  a  day,  or  more  frequently  if  neces- 
sary to  afford  relief. 

In  a  few  hours  the  pain  is  generally  relieved,  and  the  discharge 
returns,  but  in  obstinate  cases,  to  prevent  orchitis,  a  dozen  or  more 
leeches  should  be  applied  to  the  perineum  and  the  medicine  con- 
tinued. After  the  subsidence  of  the  pain  and  the  restoration  of  the 
discharge  the  case  should  be  treated  as  before,  except  that  great  care 
should  be  taken  to  stop  the  discharge  gradually  in  order  to  prevent 
a  return  of  the  same  symptoms. 

Some  years  since  many  eminent  physicians  were  opposed  to  the 
use  of  injections  in  the  treatment  of  gonorrhoea.  The  first  essay  I 
prepared  on  a  medical  subject  was  read  before  the  Medical  Society 
of  the  Transylvania  University  against  their  use  in  this  disease.  I 
now,  however,  entertain  an  opinion  very  different  from  the  one  I 
then  expressed,  so  different  that  I  believe  that  the  disease  can  seldom 
be  cured  without  them,  and  the  only  change  which  experience  has 
induced  me  to  make  is  to  diminish  their  strength.  Formerly  I  used 
twenty  grains  of  the  sulphate  of  zinc  to  eight  ounces  of  water,  and 
now  only  from  twelve  to  sixteen,  and  with  it  I  usually  combine 
half  an  ounce  of  the  wine  or  tincture  of  opium.  If  the  disease  has 
existed  for  several  weeks,  or  if  it  be  a  case  of  gleet,  the  injection 
should  be  thrown  as  far  into  the  urethra  as  possible,  retained  five 
minutes,  and  continued  at  least  ten  days  after  the  discharge  has 
ceased.  The  reason  that  so  many  fail  to  cure  gonorrhoea,  and  that 
so  many  cases  of  stricture  occur,  is  that  as  soon  as  the  discharge  is 
checked  the  remedies  are  discontinued,  and  in  three  or  four  days  the 
difficulty  returns.  I  have  endeavored  to  ascertain  the  time  neces- 
sary to  continue  the  treatment,  and  feel  satisfied  that  ten  days  are 
always  required  to  prevent  a  return  of  the  discharge.  After  the  in- 
flammatory symptoms  have  disappeared,  should  a  slight  discharge 
continue,  a  large  metallic  bougie  should  be  introduced  at  least  three 
times  a  week,  and  be  allowed  to  remain  from  twenty  to  thirty  min- 
utes. Nothing  seems  to  remove  the  distended  and  relaxed  condi- 


LECTURE    XVII.  —  GLEET.  217 

tion  of  the  vessels  so  speedily  and  effectually.  I  have  by  its  use 
cured  many  cases  of  gleet  that  had  resisted  the  ordinary  treatment 
for  months,  and  even  years,  in  which  there  existed  merely  a  con- 
gested and  thickened  condition  of  the  mucous  membrane.  You 
should  not  mistake  the  discharge  which  occurs  in  gleet  for  sperma- 
torrhoea, which  in  California  is  very  common.  In  the  former  the 
discharge  is  generally  yellowish,  thin,  and  stains  the  linen,  whilst  in 
sperm atorrhcea  it  resembles  albumen,  is  transparent,  tenacious,  and 
appears  generally  either  when  at  stool  or  after  an  erection.  This 
disorder  is  often  treated  as  a  gleet,  to  the  injury  of  the  patient,  as 
will  be  hereafter  more  fully  explained.  Besides  the  discharge,  in 
gleet  there  sometimes  exists  in  the  urethra  a  want  of  elasticity,  which 
requires  besides  the  remedies  already  recommended  the  use  of  ex- 
ternal applications,  such  as  the  tincture  of  iodine,  which  may  be 
applied  with  a  camel's-hair  pencil  to  the  skin,  over  and  in  the  di- 
rection of  the  urethra,  or  mercurial  ointment,  which  should  be  spread 
upon  lint,  and  kept  in  contact  with  the  part  affected  by  the  use  of  a 
bandage.  To  prevent  painful  erections  at  night,  either  in  gleet  or 
gonorrhoea,  give  from  five  to  ten  grains  of  camphor  at  bedtime,  or 
introduce  one  grain  of  opium  into  the  rectum,  either  of  which  will 
give  temporary  relief  until  the  cause  can  be  removed. 


L  I  B  K  A  U  V 

UNIVERSITY   OF 

CALIFORNIA.  J 


218  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE    XVIII. 

GENTLEMEN  :  During  the  treatment  of  gonorrhoea,  as  I  have  al- 
ready mentioned,  the  discharge  sometimes  ceases  suddenly,  the  neck 
of  the  bladder  becomes  inflamed,  and  if  the  difficulty  is  not  properly 
treated  the  inflammation  will  extend  to  the  testicles,  although  it  is 
generally  confined  to  one  side,  and  may  be  called  either  orchitis  or 
hernia  humoralis.  The  pain  is  always  distressing,  and  in  some  cases 
both  constant  and  excruciating;  it  frequently  extends  up  the  sper- 
matic cord  to  the  loins.  The  organ  generally  swells  rapidly,  partly 
because  of  the  distension  of  the  vessels,  and  partly  because  of  the  ac- 
cumulation of  serum  in  the  tunica  vaginalis,  produced  by  inflamma- 
tion of  the  serous  membrane. 

Treatment. — This  should  be  both  general  and  local.  Either  a 
sufficient  number  of  leeches  should  be  applied  to  the  scrotum  to  ab- 
stract six  or  eight  ounces  of  blood,  or,  which  is  decidedly  more  ex- 
peditious and  equally  effectual,  the  scrotum  should  be  punctured 
with  a  lancet,  from  two  to  five  punctures  being  made.  Should  any 
difficulty  be  experienced  in  arresting  the  haemorrhage,  either  Monsel's 
salt  should  be  applied,  or  a  small  pin  be  used  as  recommended  in 
my  lecture  on  haemorrhage.  When  the  scrotum  contains  serum,  the 
lancet  should,  at  one  point,  pass  through  the  tunica  vaginalis  to 
allow  it  to  escape  and  remove  the  pressure,  which  is.  always  painful. 
This  method  of  depletion  will  afford  relief. 

The  best  external  application  is  a  tobacco  poultice,  which  may  be 
prepared  with  either  cut  or  twist  tobacco ;  but  the  leaves  wet  with 
warm  water,  and  applied  four  or  five  double,  are  preferable  to  either. 
Tartar  emetic  has  unquestionably  great  influence  over  these  organs. 
Twenty  years  ago  I  relied  upon  it  entirely  in  such  cases.  The  pain 
usually  disappears  as  soon  as  vomiting  occurs,  which,  however,  to 
most  patients  is  more  unpleasant  than  the  disease  itself.  I  now  give 
a  combination  of: 

R.— Vin.  Col.Sem., 5J. 

Tinct.  Pip.  Cub., ^iv. 

Morph.  Acetat., gr.  v. 

M.  Sig.  Take  one  teaspoonful  every  three  hours. 


LECTURE    XVIII. — SEQUELAE    OF    GONORRHOEA.  219 

This  with  the  other  remedies  will  afford  relief;  and  when  that  has 
been  obtained,  the  mixture  should  either  be  given  at  longer  intervals 
or  the  quantity  diminished,  and  continued,  with  the  occasional  admin- 
istration of  purgatives,  until  the  inflammation  subsides  and  the  dis- 
charge returns.  Sometimes  when  orchitis  is  neglected  or  inefficiently 
treated,  suppuration  takes  place,  which  may  destroy  the  function  of 
the  organ.  I  have  found  scrofulous  subjects  most  liable  to  this  dif- 
ficulty, and  when  in  such  cases  it  does  occur,  a  long  and  well-directed 
course  of  medical  treatment  is  required  to  save  the  organ,  even  with 
a  loss  of  its  function.  In  favorable  cases  when  the  inflammation 
subsides,  the  epididymis  sometimes  remains  enlarged  and  indurated, 
which  will  render  the  use  of  a  sorbefacient  necessary  to  remove  the 
difficulty.  In  such  cases  I  have  found  the  ungt.  hyd.  mitis,  when 
spread  upon  thin  chamois  leather,  and  kept  constantly  applied  by 
the  use  of  a  suspensory  bandage,  superior  to  the  tincture  of  iodine, 
which,  even  when  diluted,  produces  so  much  irritation  of  the  skin 
that  it  frequently  becomes  necessary  to  discontinue  its  use  before  its 
full  effect  has  been  obtained.  You  will  frequently  meet  with  cases 
of  gonorrhoea  in  which  injections,  even  of  the  mildest  character,  have 
a  decidedly  injurious  effect,  being  always  followed  either  by  inflam- 
mation of  the  neck  of  the  bladder  or  by  orchitis,  so  soon  as  the  dis- 
charge is  arrested.  In  such  cases,  if  the  habit  be  full,  apply  leeches 
to  the  perineum,  give  the  remedies  already  enumerated  internally, 
and  when  the  discharge  becomes  thin  and  the  quantity  is  greatly 
diminished,  I  have  found  the  iodide  of  potassium  very  useful.  It 
controls  the  action  of  the  capillaries  of  the  mucous  membrane,  and 
when  combined  with  the  judicious  use  of  the  bougie,  will  generally 
supersede  the  necessity  of  resorting  to  other  remedies.  It  is  partic- 
ularly useful  when  some  thickening  and  induration  of  the  mucous 
membrane  of  the  urethra  exists,  which  if  neglected  will  result  in 
stricture,  which  is  one  of  the  most  unpleasant  consequences  of  this 
troublesome  disease.  Stricture  may  be  produced  either  by  a  thick- 
ening and  induration  of  the  mucous  membrane  of  the  urethra,  or  by 
the  deposition  and  organization  of  plastic  lymph  around  the  canal, 
by  which  its  calibre  is  diminished.  A  stricture  may  be  either  soft 
or  indurated;  the  former  is  much  more  simple,  yields  more  readily 
to  treatment,  and  is  much  less  liable  to  return.  Some  writers  describe 
what  they  call  spasmodic  stricture,  but  I  must  confess  that  I  have 
never  met  with  a  case  of  that  character.  Sometimes  in  gonorrhoea, 


220  LECTURES    ON    PRACTICAL    SURGERY. 

when  considerable  inflammation  exists,  the  patient  will  find  it  either 
difficult  or  impossible  to  pass  the  urine,  which  results  from  the  swell- 
ing of  the  mucous  membrane  and  not  from  a  spasmodic  contraction. 
The  best  proof  I  can  offer  of  the  correctness  of  this  opinion  is  that  the 
introduction  of  a  catheter  is  always  in  such  cases  followed  by  haemor- 
rhage, which  in  quantity  corresponds  with  the  violence  of  the  inflam- 
mation. A  muscle  cannot  act  without  rest  more  than  ten  minutes, 
and  if  you  were  to  meet  with  a  case  of  spasmodic  stricture,  all  that 
is  necessary  is  to  press  the  extremity  either  of  a  bougie  or  catheter 
gently  and  steadily  against  the  point  of  resistance,  and  it  will  yield. 
A  soft  stricture,  which  results  from  vascular  distension  of  the 
mucous  membrane  of  a  portion  of  the  urethra,  can  be  easily  and 
speedily  removed  by  dilatation.  In  such  cases  never  employ  elastic 
bougies;  when  large  they  are  passed  with  difficulty,  and  always  do 
more  or  less  violence  to  the  prostatic  portion  of  the  urethra,  provided 
they  be  sufficiently  large  and  strong  to  overcome  a  troublesome  stric- 
ture. Very  small  metallic  instruments  are  also  objectionable  in 
consequence  of  the  danger  of  lacerating  the  urethra,  which  is  always 
an  unfortunate  occurrence,  and  when  followed  by  urinary  infiltration 
is  highly  dangerous.  Should  the  contraction  in  such  cases  be  so 
great  that  the  urine  will  not  pass  even  in  a  small  stream,  the  patient 
should  be  placed  upon  the  back,  and  a  No.  2  or  3  silver  catheter 
should  be  passed,  until  the  point  of  the  instrument  rests  against  the 
obstruction,  and  retained  there  fifteen  or  twenty  minutes  under  gentle 
pressure  before  a  second  effort  is  made  to  pass  it  through  the  stric- 
ture. But  little  force  should  be  employed  at  first,  and  if  much  diffi- 
culty be  experienced  in  passing  the  stricture,  the  effort  should  be  re- 
newed every  alternate  day,  until  the  obstruction  is  overcome.  The 
size  of  the  instrument  should  be  gradually  increased,  until  the  canal 
is  restored  to  its  original  dimensions ;  during  the  treatment,  should 
the  discharge  continue,  I  have  found  the  perchloride  of  iron,  half  a 
drachm  to  eight  ounces  of  water,  if  thrown  into  the  urethra  with  a 
large  penis  syringe,  and  retained  three  or  four  minutes,  superior  to 
any  other  injections  that  can  be  employed.  The  bougie  should  not 
at  first  be  allowed  to  remain  long  in  the  bladder,  or  even  in  the 
urethra,  as  its  presence  frequently  produces  so  much  irritation  as  to 
be  followed  directly  by  a  protracted  chill  and  violent  fever,  or  even 
by  a  succession  of  paroxysms.  When  a  difficulty  of  this  character 
is  apprehended,  a  narcotic  should  be  administered.  Some  entertain 


LECTURE    XVIII.  —  URETflRAL    STRICTURE.  221 

a  high  opinion  of  aconite,  yet  from  my  experience  I  do  not  think  it 
is  equal  either  to  a  quarter  of  a  grain  of  the  sulph.  morph.,  or  a  wine- 
glassful  of  brandy,  or  any  other  alcoholic  stimulant  given  soon  after 
the  instrument  has  been  removed.  The  pressure  produced  by  the 
weight  of  the  hand,  even  if  the  instrument  be  small,  will  not  lacer- 
ate, but  it  will  dilate  the  urethra,  as  the  mucous  membrane,  even 
when  indurated,  cannot  resist  the  action  of  a  metallic  instrument. 

When  a  stricture  results  either  from  a  cicatrix  or  from  the  depo- 
sition and  organization  of  plastic  lymph,  the  treatment  becomes  not 
only  more  tedious  and  difficult,  but  also  requires  more  skill.  Be- 
sides many  of  the  same  character  which  I  have  treated,  three  have 
occurred  within  the  last  year  that  had  resisted  the  use  of  the  bougie 
for  six  months  in  the  hands  of  respectable  physicians  in  this  city. 
In  one  case  the  injury  was  produced  by  the  rope,  to  which  a  bucket 
was  attached,  and  in  which  a  man  was  descending  into  the  main 
shaft  of  the  Gould  &  Curry  mine,  having  parted  several  feet  from 
the  bottom ;  his  perineum  was  resting  upon  the  edge  of  the  vessel, 
and  with  the  urethra,  was  so  much  contused  that  retention  of  urine 
resulted  from  the  accident.  It  ultimately  became  necessary  to  punc- 
ture the  bladder  through  the  rectum  to  afford  relief.  The  perineum, 
in  consequence  of  the  infiltration  of  urine  which  resulted  from  the 
injury,  sloughed,  and  a  perineal  fistula  remained,  with  a  stricture 
which  would  not  admit  the  smallest  metallic  bougie.  Even  in  this 
case,  which  was  one  of  the  most  aggravated  character,  I  succeeded 
by  dilatation.  The  extremity  of  the  smallest  instrument  was  held 
firmly  in  contact  with  the  cicatrix  for  half  an  hour  every  evening, 
until  ulceration  took  place,  and  it  passed  into  the  bladder.  The 
bougie  was  then  introduced  every  alternate  night,  retained  half  an 
hour,  and  the  size  gradually  increased  until  a  No.  12  passed  through 
easily  and  without  pain.  He  was  then  directed  to  use  the  bougie 
every  week  for  several  months.  So  soon  as  the  natural  channel  for 
the  urine  was  restored,  the  fistula  healed,  and  in  three  months  the 
man  left  the  city  entirely  relieved.  Of  the  other  cases  referred  to, 
in  one  the  stricture  was  produced  by  a  fall  from  a  stable  loft  upon 
the  edge  of  a  manger,  and  in  the  other  from  being  crushed  in  a 
tunnel,  the  bones  of  the  pelvis  and  thigh  being  fractured  at  the  same 
time.  They  were  both  treated  in  the  same  manner,  and  with  a  sim- 
ilar result.  Should  a  stricture,  when  that  is  possible,  be  divided  by 
one  of  the  cutting  instruments  used  for  that  purpose,  if  the  bougie 


222 


LECTURES    ON    PRACTICAL    SURGERY. 


is  not  used  properly,  the  wound  will  heal,  and  the  contraction  become 
as  great  as  before  the  operation  was  performed. 


FIG.  59. 


FIG.  60. 


Fig.  59  shows  an  instrument  for  cutting  strictures,  the  long  flexible  tip,  d,  serving  as  a  guide. 
Within  the  stem,  A,  there  runs  a  rod,  R,  carrying  the  small  blade,  a. 

Fig.  60  represents  another  form.  A  fine  whalebone,  B,  being  passed  through  the  stricture,  and 
the  instrument,  C,  slipped  over  it,  being  tunnelled  from  A  to  F  for  this  purpose. 

In  indurated  stricture,  which  usually  results  from  gonorrhoea,  the 
same  treatment  should  be  adopted,  except  that  a  No.  3  silver  catheter 


LECTURE    XVIII.  —  TREATMENT    OF    STRICTURE.  223 

should  be  preferred,  which  in  five  minutes  will  dilate  the  stricture 
without  the  slightest  risk  of  producing  a  false  passage  by  lacerating 
the  urethra.  The  bougie  should  not  be  passed  oftener  than  every 
forty-eight  hours,  should  be  allowed  to  remain  about  half  an  hour, 
and  should  be  used  once  a  week  for  at  least  a  year  to  prevent  a 
recurrence  of  the  difficulty.  Although  my  practice  in  this  class  of 
diseases  has  been  very  extensive,  I  have  never  found  a  case  of  stric- 
ture that  could  not  be  cured  by  dilatation,  unless  the  urethra  had 
been  torn  and  a  false  passage  made  before  it  came  under  my  care.  As 
long  as  I  have  practiced  surgery,  I  have  never  punctured  the  blad- 
der but  once  for  retention  of  urine,  and  in  that  case  a  false  passage 
had  been  made  which  rendered  it  impossible  to  pass  the  catheter. 
Byrne's  operation  was  subsequently  performed,  and  the  patient  re- 
covered sufficiently  to  return  home,  although  not  entirely  cured.  In 
conclusion  I  beg  leave  to  repeat,  except  to  relieve  the  bladder  when 
that  organ  is  paralyzed,  never  use  a  gum  catheter,  and  then  the  in- 
strument should  be  small,  because  when  large  it  lodges  against  the 
prostate  gland,  and  if  this  be  repeated  frequently  it  produces  inflam- 
mation of  that  organ,  which  is  always  exceedingly  difficult  to  con- 
trol. The  gum-elastic  catheter  is  not  only  more  difficult  to  intro- 
duce, but  it  gives  more  pain  when  it  is  removed,  in  consequence  of 
the  urethra  adhering  more  closely  to  it  than  it  would  to  a  polished 
metallic  instrument.  You  cannot  cure  a  stricture,  either  when  in- 
durated or  resulting  from  a  wound,  by  the  use  of  an  elastic  bougie, 
•no  matter  how  long  or  how  skilfully  it  may  be  used.  The  metallic 
bougie  by  its  hardness  produces  absorption  of  the  organized  deposit 
more  rapidly,  is  much  more  easily  introduced,  is  less  painful  when 
in  the  stricture,  and  can  be  removed  with  much  less  difficulty  than 
any  instrument  made  of  either  gutta-percha  or  gum-elastic.  In 
some  cases,  the  urethra  becomes  so  contracted  that  the  flow  of  urine 
is  entirely  prevented,  the  bladder  gradually  distends,  and  if  not 
relieved,  the  parietes  will  yield  to  the  pressure  of  the  contents,  and 
death  will  result  from  the  escape  of  the  urine  into  the  peritoneal 
cavity. 

In  a  case  of  this  character,  before  the  distension  becomes  too  great, 
place  the  patient  upon  the  back,  with  the  head  and  knees  somewhat 
elevated,  and  the  thighs  separated  so  that  the  fingers  of  the  left  hand 
can  be  placed  upon  the  perineum.  Seat  yourself  upon  the  right 
side,  with  the  determination  to  pass  a  No.  4  silver  catheter  before 


224  LECTURES    ON    PRACTICAL    SURGERY. 

changing  your  position.  I  prefer  a  catheter  of  that  size,  because  you 
can  use  more  force  with  less  danger  of  lacerating  the  urethra.  Great 
patience  is  required  to  overcome  the  difficulty,  and  gentleness  and 
caution  are  both  especially  important,  for  should  the  canal  be  lacer- 
ated it  would  be  impossible  to  pass  the  instrument  into  the  bladder. 
I  have  never  failed  but  once,  and  if  I  had  treated  that  case  before 
the  urethra  was  lacerated,  I  do  not  believe  that  I  would  have  expe- 
rienced much  difficulty,  although  it  was  one  of  an  exceedingly  aggra- 
vated character.  When  the  catheter  fails,  the  bladder  should  be 
punctured  through  the  rectum  with  the  long  curved  trocar  exhibited. 
Oil  the  forefinger  of  the  left  hand  and  pass  it  into  the  rectum,  in 
order  to  ascertain  the  position  of  the  prostate  gland.  The  trocar 
should  then  be  introduced  by  the  side  of  the  finger  until  the  point 
rests  upon  the  bladder,  about  an  inch  above  the  prostate  gland  ;  then 
by  a  sudden  motion  it  is  forced  into  the  cavity.  So  soon  as  the 
trocar  is  removed  the  urine  will  escape  through  the  canula,  and  in- 
stant relief  is  afforded.  The  canula  should  be  allowed  to  remain, 
and  can  easily  be  retained  by  a  T  bandage  until  the  urethra  is  suffi- 
ciently dilated  to  render  its  presence  unnecessary.  When  I  performed 
this  operation,  I  would  have  felt  humiliated,  if  the  case  had  not  been 
improperly  treated  before  I  made  the  effort  to  pass  the  catheter. 

When  a  perineal  fistula  will  not  heal  after  the  canal  has  been  di- 
lated, or  when  it  is  impossible  to  introduce  an  instrument  into  the 
bladder,  Syme's  operation  should  be  performed.  The  patient  being 
placed  in  the  position  required  in  the  operation  of  lithotomy,  a  silver 
catheter  should  be  passed  to  the  point  of  obstruction,  and  the  ex- 
tremity of  the  instrument  exposed  by  a  free  incision,  which  should 
extend  an  inch  below,  in  the  direction  of  the  urethra.  A  grooved 
director  should  then  be  passed  into  the  bladder,  which  will  conduct 
or  direct  the  catheter  into  the  cavity,  where  it  should  be  allowed  to 
remain  at  least  ten  days,  and  when  removed  another  should  be  in- 
troduced, and  changed  every  three  or  four  days  until  the  external 
wound  heals,  when  the  case  should  be  treated  as  one  of  ordinary 
stricture. 

The  most  remarkable  and  unpromising  case  of  this  character  I  have 
ever  treated,  was  published  some  years  since  in  the  Charleston  Medical 
Journal.  James  Smith,  a  boy,  aged  sixteen  years,  was  crushed  at 
Tower  Hill,  California,  by  a  bank  of  earth.  The  bones  of  the  pelvis 
were  fractured ;  both  the  urethra  and  bladder  were  ruptured,  and  the 


LECTURE    XVIII.  —  TREATMENT    OF    STRICTURE.  225 

urine  escaped  through  fistulous  openings  in  the  groin  and  perineum. 
The  patient  having  been  abandoned  as  incurable,  he  was  sent  to  the 
country  in  order  to  improve  his  general  health,  and  when  he  returned 
in  three  months  the  operation  was  performed  as  directed.  After 
exposing  the  catheter,  the  first  effort  made  to  pass  the  director  was 
successful.  The  extremity  of  the  catheter  was  then  placed  in  the 
groove,  and  it  glided  readily  into  the  bladder.  The  opening  in  the 
groin  soon  healed,  and  when  his  health  was  entirely  restored  he  re- 
turned to  Illinois,  and  is  now  in  good  health,  and  the  father  of  a 
large  family. 

Should  infiltration  of  urine  occur  from  the  improper  use  of  instru- 
ments, the  most  serious  consequences  may  be  apprehended.  The 
patient  very  soon  exhibits  evidences  of  the  greatest  possible  distress, 
the  pulse  becomes  feeble  and  rapid,  the  extremities  cold,  the  respi- 
ration difficult,  and  delirium  is  not  an  unusual  accompaniment.  If 
the  local  irritation  is  not  speedily  relieved  by  free  incisions,  death 
will  soon  follow.  The  incisions  or  punctures  should  be  as  extensive 
as  the  infiltration,  and  after  the  urine  has  been  pressed  out,  cloths 
wet  with  warm  water,  fomentations,  or  the  warm-water  dressing, 
should  be  applied.  Give  alcoholic  stimulants  freely,  apply  heat  ex- 
ternally, and  indeed  employ  every  means  within  your  control  calcu- 
lated to  counteract  the  general  prostration  which  invariably  results 
from  such  a  difficulty.  If  the  urine  cannot  be  removed,  the  parts 
exposed  to  its  action  soon  become  gangrenous,  with  the  symptoms 
described  in  my  lecture  on  the  subject  of  the  terminations  of  inflam- 
mation. 

In  stricture  the  best  internal  remedy  is  the  iodide  of  potassium  ; 
it  acts  on  the  absorbents,  and  aids  very  materially  the  use  of  the 
bougie.  It  may  be  given  alone,  or  in  combination  with  the  tinct,  of 
belladonna  and  aconite,  and  if  the  bowels  be  constipated,  the  fluid 
ext.  of  senna  should  be  added,  oiij  to  a  §vj  mixture.  I  have  already 
directed  your  attention  to  inflammation  of  the  bladder  as  a  conse- 
quence of  gonorrhoea,  and  now  I  propose  to  detain  you  a  short  time 
in  describing  the  symptoms  and  treatment  of  a  disease,  which  I  fear 
you  will,  when  you  arrive  at  my  age,  regard  as  one  of  the  most  ob- 
stinate, if  not  incurable,  of  human  maladies. 

Catarrh  of  the  Bladder. — This  results  from  inflammation,  fre- 
quently of  a  gonorrhoea  I  character,  that  has  been  neglected  until  the 
mucous  membrane  becomes  thickened,  indurated,  and  even  ulcerated, 

15 


226  LECTURES    ON    PRACTICAL    SURGERY. 

which  accounts  for  the  immense  discharge  of  mucous  and  muco- 
purulent  matter  which  the  urine  deposits.  Four  ounces  frequently 
contain  one  of  mucus,  or  of  a  mixture  of  pus  and  mucus,  according 
to  the  stage  and  violence  of  the  disease.  The  coats  of  the  bladder 
not  only  become  thickened  and  irregular,  but  the  capacity  of  the 
organ  is  greatly  diminished,  which,  combined  with  the  irritability  of 
the  mucous  membrane,  renders  it  necessary  to  pass  the  urine  very 
frequently,  which  is  almost  always  exceedingly  painful. 

Various  remedies  have  been  recommended  in  such  cases,  and  they 
occasionally  prove  successful.  Dupuytren's  favorite  prescription  was 
ol.  terebinth,  in  ten-drop  doses  three  times  a  day,  with  counterirri- 
tation  over  the  hypogastric  region,  either  with  croton  oil  or  tartar 
emetic  ointment.  In  an  exceedingly  obstinate  case  in  this  city,  I 
effected  a  cure  by  the  use  of  croton  oil  as  a  counterirritant,  and  the 
administration  of  two  capsules  three  times  a  day,  composed  of  cu- 
bebs  and  copaiba.  Benzoic  acid  has  in  some  cases  a  very  happy 
effect,  particularly  when  combined  with  some  preparation  of  opium. 
The  following  is  the  best  combination  of  remedies  which  I  have 
found  in  cases  of. this  character: 

R. — Acid.  Benzoic., 

Tinct.  Belladonnse,  aa    .......  giij. 

"       Aconit.  Rad., gj. 

Spts.  Vin.  Rectif., gj. 

Morph.  Sulph., gr.  iv. 

Syr.  Zingiberis,     ........  Jiiss. 

M.  Sig.  Take  one  teaspoonful  every  six  hours. 

The  effect  of  the  morphia  is  exceedingly  pleasant  when  the  desire 
to  pass  the  urine  is  very  frequent.  The  fluid  ext.  of  buchu  is  almost 
always  prescribed  in  this  disease,  and  I  suppose  must  possess  prop- 
erties which  entitle  it  to  the  confidence  of  the  profession,  but  I  am 
compelled  to  say  that  I  have  never  been  able  to  satisfy  myself  that 
it  really  possesses  the  merits  ascribed  to  it  in  cases  of  this  character. 
In  simple  irritation  of  the  bladder  it  may  be  useful,  but  in  this  dis- 
ease it  is  not  only  inferior  to  the  remedies  enumerated,  but  also  to 
uva  ursi.  This  should  be  given  in  infusion,  Sj  of  the  leaves  being 
sufficient  for  a  pint  of  boiling  water,  which  should  be  taken  every 
day.  When  one  remedy  loses  its  effect,  another  should  be  substi- 
tuted, or  a  combination  made  according  to  the  indications  which  the 


LECTURE    XVIII.  —  CATARRH    OF    THE    BLADDER.  227 

case  presents ;  and  you  will  find  that  the  beneficial  effect  of  every 
remedy  which  has  been  prescribed  in  cases  of  this  character  is  greatly 
increased  by  the  use  of  some  preparation  of  opium. 

Remedies  are  sometimes  applied  to  the  mucous  membrane  of  the 
bladder  by  introducing  a  silver  catheter,  to  which  a  syringe  is 
attached.  The  instrument  exhibited  is  preferable  to  any  other  in 
consequence  of  its  simplicity,  and  with  it  the  fluid,  after  reaching 
the  bladder,  can  very  easily  be  prevented  from  escaping.  The 
solution,  whether  it  be  of  alum,  nitrate  of  silver,  sulphate  or 
chloride  of  zinc,  or  any  other  astringent,  should  be  carefully  used. 
The  injection  should  neither  be  too  strong,  nor  allowed  to  remain 
long  enough  to  produce  either  much  pain  or  uneasiness.  It  may  be 
repeated  every  alternate  day.  When  blood  follows  even  the  in- 
troduction of  a  catheter,  the  solutions  of  iron  are  improper,  as  the 
coagulum  might  be  too  large  to  pass  through  the  urethra,  and  serve 
as  a  nucleus  for  a  urinary  calculus.  I  have  always  been  disap- 
pointed by  the  use  of  injections.  I  have  tried  them  all,  and  now  I 
seldom  recommend  them,  except  to  amuse  a  patient  until  other  rem- 
edies have  time  to  act. 

Counterirritation  in  some  cases  exerts  a  decidedly  beneficial  in- 
fluence. A  seton  introduced  either  above  the  symphysis  pubis  or  in 
the  perineum,  if  the  patient  be  confined  to  bed,  has  frequently  a  good 
effect,  and  sometimes  the  application  either  of  croton  oil  or  tartar 
emetic  ointment  affords  great  relief.  To  cure  a  bad  case  of  vesical 
catarrh,  a  combination  of  the  most  active  remedies  is  required,  as 
well  as  temperance,  and  the  exercise  of  great  patience  on  the  part  of 
both  patient  and  physician. 

When  the  remedies  fail,  it  has  not  only  been  suggested  but 
practiced,  particularly  when  the  cystorrhoaa  is  complicated  with  dis- 
ease of  the  prostate  gland,  to  make  an  opening  into  the  bladder 
such  as  is  necessary  for  the  removal  of  stone,  for  the  purpose  of  re- 
lieving the  bladder  of  the  necessity  of  expelling  its  contents,  and 
for  the  benefit  that  may  result  from  the  haemorrhage  and  suppu- 
ration inseparable  from  such  an  operation. 

Prof.  Parker,  of  New  York,  was  the  first  to  perform  this  oper- 
ation, and  although  the  patient  died  of  disease  of  the  kidneys  and 
lungs,  it  afforded  great  relief.  I  have  operated  twice  in  this  State 
within  the  last  five  years.  The  first  operation  was  performed  on  the 
corner  of  Stockton  and  Geary  Streets.  The  prostate  was  enlarged, 


228  LECTURES    ON    PRACTICAL    SURGERY. 

and  the  disease  of  the  bladder  was  not  even  alleviated  by  the  reme- 
dies usually  prescribed.  The  operation  was  followed  by  profuse  and 
repeated  haemorrhage,  and  the  wound  did  not  close  until  the  twenty- 
seventh  day.  The  patient  left  the  city  greatly  improved,  and  has 
since  entirely  recovered.  The  other  patient  was  from  Oregon.  He 
was  examined  by  Drs.  Morse,  Burnett  and  Badarous,  and  no  stone 
being  detected,  in  consequence  of  the  distressing  character  of  the 
symptoms,  and  the  relief  afforded  in  the  other  case  by  an  operation, 
I  determined  to  pursue  the  same  course.  Instant  relief  was  afforded, 
and  the  symptoms,  which  were  previously  so  distressing,  did  not  re- 
turn until  the  wound  had  nearly  closed.  Then  he  had  a  chill,  which 
was  followed  by  a  fever  that  continued  until  the  cicatrix  ulcerated, 
which  relieved  the  bladder.  The  urine  one  year  after  the  operation 
passed  through  the  urethra,  and  could  be  retained  about  forty  min- 
utes, which  was  much  longer  than  before,  and  its  evacuation  was 
much  less  painful.  The  only  reward  I  received  for  the  attention 
bestowed  upon  the  case,  was  a  demand  of  ten  thousand  dollars  or  a 
suit  for  malpractice.  The  money  was  never  paid,  nor  was  the  suit 
instituted. 

Professor  Gross,  in  his  work  On  the  Diseases  of  the  Urinary  Organs, 
says  that  should  a  favorable  case  present,  he  would  not  hesitate 
to  operate,  and  in  a  private  letter  addressed  to  me  he  expresses  the 
belief  that  it  will  soon  be  recognized  as  a  legitimate  operation.  I 
will  certainly  perform  it  whenever  other  remedies  fail  to  afford  relief, 
in  defiance  of  the  danger  of  suits  for  malpractice,  which  patients  are 
often  advised  to  bring  by  the  less  fortunate  and  unprincipled  mem- 
bers of  the  profession.  When  this  course  is  adopted,  the  wound 
should  be  prevented  from  healing  for  several  weeks,  by  the  occa- 
sional introduction  of  a  female  catheter  or  some  other  small  metallic 
instrument. 

Hgematuria,  or  haemorrhage  from  the  mucous  coat  of  the  bladder, 
is  not  a  very  uncommon  occurrence.  It  may  result  from  the  intro- 
duction of  instruments,  from  violence,  or  from  the  laceration  of  the 
vessels  from  overdistension  of  the  organ.  When  the  blood  is  limited 
in  quantity  it  will  be  readily  expelled,  but  when  the  bladder  is  so 
much  distended  as  to  be  unable  to  relieve  itself,  a  large  silver  catheter 
should  be  introduced,  and  a  syringe  so  adjusted  that  the  blood  can  be 
drawn  out  through  the  catheter.  Should  the  coagulum  be  firm,  water 
should  be  thrown  in  and  pumped  out  as  often  as  may  be  necessary 


LECTURE    XVIII. — DISEASE    OF    THE    PROSTATE.  229 

to  remove  the  difficulty.  Fortunately,  when  the  urethra  is  wounded, 
the  blood  rarely  finds  its  way  into  the  bladder.  When  it  reaches 
the  prostatic  portion  the  sphincter  contracts  and  excludes  it  entirely. 

There  yet  remains  a  very  important  disease  of  these  organs,  to 
which  I  propose  to  devote  the  few  minutes  which  remain  of  the  time 
to  which  I  am  entitled  before  finishing  this  lecture,  which  is  disease 
of  the  prostate  gland.  It  is  not  uncommon,  and  when  it  occurs  at 
an  advanced  age  it  is  absolutely  incurable,  which  is  not,  however, 
the  case  when  the  induration  and  enlargement  result  from  gonor- 
rhoea. It  is  then  curable,  although  it  yields  with  difficulty.  After 
one  or  more  attacks  of  inflammation  of  the  neck  of  the  bladder,  from 
the  sudden  suppression  of  the  discharge,  some  difficulty  is  usually  ex- 
perienced in  passing  the  urine.  If  a  bougie  or  catheter  be  introduced, 
it  will  pass  readily  until  its  extremity  reaches  the  prostate  gland,  and 
the  resistance  is  so  decided  that  the  hand  must  be  depressed  so  as  to 
elevate  the  extremity  sufficiently  to  enter  the  bladder.  Retention  of 
urine  rarely  results  from  this  form  of  the  disease,  consequently  neither 
a  bougie  nor  catheter  should  be  employed  in  the  treatment  of  such 
cases.  They  yield  most  readily  to  the  internal  use  of  the  iodide  of 
potassium  and  corrosive  sublimate.  Should  the  enlargement  be  con- 
siderable, counterirritants  applied  to  the  perineum  are  especially  effica- 
cious. A  seton  may  be  introduced,  or  the  tincture  of  iodine  applied, 
so  as  to  keep  up  considerable  irritation  without  rendering  the  patient 
unable  to  take  active  exercise.  When  this  disease  is  the  result  of 
age,  the  gland  is  not  only  enlarged  but  also  greatly  indurated.  The 
enlargement  may  become  so  great  as  to  obstruct  the  urethra,  so  that 
it  is  impossible  to  pass  an  ordinary  silver  catheter  without  curving 
it  greatly  near  the  extremity,  and  then  it  often  is  necessary  to  pass 
the  forefinger  into  the  rectum  to  give  it  the  proper  direction.  In 
aggravated  cases,  when  the  patient  is  not  convenient  to  his  physician, 
or  when  the  gland  is  enormously  enlarged,  particularly  the  middle 
lobe,  an  opening  should  be  made  and  established  from  the  rectum  to 
the  bladder,  which  not  only  affords  great  and  instant  relief,  but  also 
enables  the  patient  to  dispense  with  the  use  of  the  catheter,  which  is 
always  in  such  cases  a  source  of  pain  and  annoyance. 

During  the  first  year  I  practiced  medicine,  I  was  called  to  see  a 
Mr.  Williams,  an  old  Revolutionary  soldier,  whose  bladder  was  ex- 
cessively distended  from  this  cause.  A  catheter  was  introduced  and 
secured,  but  in  two  or  three  days  it  escaped,  and  this  was  followed 


230  LECTURES    ON    PRACTICAL    SURGERY. 

by  retention  of  urine.  His  residence  being  sixteen  miles  distant, 
I  made  an  opening  with  a  bistoury  from  the  rectum,  which  was 
sufficiently  large  to  become  fistulous,  and  he  lived  five  or  six 
years,  more  comfortably  than  for  many  years  before  the  operation 
was  performed. 


LECTURE    XIX.  —  WOUNDS.  231 


LECTURE   XIX. 

GENTLEMEN  :  This  morning  I  propose  to  lecture  on  wounds  and 
bruises  or  contusions. 

A  bruise  is  an  injury  caused  by  a  blow,  either  with  or  without  a 
solution  of  continuity.  Contusions  vary  in  degree,  according  to  the 
amount  of  violence  offered  to  the  part  injured.  A  slight  contusion 
would  result  from  striking  your  hand  against  that  table,  and  if 
greater  violence  was  offered,  one  of  a  much  more  serious  character 
would  result.  After  the  receipt  of  such  an  injury  the  swelling 
corresponds  with  the  violence  and  location.  An  extravasation  of 
blood  usually  occurs,  which  is  called  ecchymosis.  The  part  then 
becomes  livid,  and  if  the  quantity  effused  is  not  so  great  as  to  render 
its  artificial  removal  necessary,  in  a  short  time  by  the  action  of  the 
absorbents  it  presents  various  shades  of  color;  from  dark  it  gen- 
erally becomes  green,  then  yellow,  and  ultimately  the  part  presents 
no  evidence  of  having  been  injured.  When  the  upper  part  of  the 
face  becomes  discolored  by  a  blow,  leeches  are  frequently  applied 
with  the  expectation  that  they  will  remove  the  extravasated  blood, 
but  instead  of  obtaining  that  result  the  difficulty  is  always  greatly 
aggravated.  In  consequence  of  which,  I  advise  you  never  to 
apply  leeches  either  to  the  face  or  temples,  particularly  in  females, 
for  besides  the  effect  already  described,  they  leave  a  scar  or  cicatrix 
which  is  more  or  less  conspicuous  according  to  the  location.  When 
the  local  abstraction  of  blood  becomes  necessary,  it  should  be 
taken  from  a  part  which  is  not  usually  exposed.  When  the  quantity 
effused  is  too  great  to  be  absorbed,  the  integument  should  be 
punctured  with  a  lancet,  and  a  tent  introduced  to  prevent  union  by 
the  first  intention.  In  contusions  of  the  face,  cold  water  is  pref- 
erable to  any  other  local  remedy,  and  when  constantly  applied  the 
discoloration  will  generally  disappear  in  a  few  days.  When  a  more 
active  remedy  can  be  employed,  the  evaporating  lotion  will  be  found 
very  useful,  which  is  composed  of  one  part  of  alcohol  and  ten  of 
water.  It  evaporates  rapidly,  and  the  heat  of  the  part  is  pro- 
portionably  diminished.  Aqua  ammonise  is  frequently  combined 
with  water  to  produce  the  same  effect,  or  in  other  words  to  prevent 


232  LECTURES    ON    PRACTICAL    SURGERY. 

the  occurrence  of  inflammation  in  the  part  injured.  Sulphuric  ether 
is  more  volatile  than  ammonia,  and  may  occasionally  be  found  use- 
ful. Vinegar,  diluted  with  an  equal  quantity  of  water  and  kept  con- 
stantly applied,  will  be  found  sufficiently  active  in  many  cases.  The 
best  application  I  have  ever  made,  either  to  relieve  pain  and  prevent 
inflammation  or  to  remove  it  after  it  has  been  developed,  is  com- 
posed of  the  following  ingredients  : 

R.— Plumb.  Acetatis, gj. 

Tinct.  Opii, £ij. 

"      Arnicas,       ........  ^iv. 

Aquae  Font.,          ........  §xxvi. 

Misce. 

During  the  day  three  or  four  folds  of  porous  cloth  or  lint  sat- 
urated with  the  solution  should  be  kept  constantly  applied,  and  at 
night  it  should  be  covered  with  oiled  silk,  to  prevent  evaporation 
and  to  avoid  the  disturbance  that  would  result  from  the  repeated 
changes  which  exposure  would  render  necessary.  When  an  ano- 
dyne is  administered,  and  the  mixture  is  applied  at  night  as  recom- 
mended, you  will  rarely  fail  to  discover  in  the  morning  a  decided 
improvement.  Erichsen  recommends  the  tincture  of  arnica,  alone 
or  combined  with  six  parts  of  water.  It  would  unquestionably  have 
a  good  effect,  but  my  own  experience  is  that  when  combined  with 
the  other  ingredients,  the  effect  will  be  much  more  satisfactory. 

In  the  treatment  of  such  cases  the  patient  must  be  kept  free  from 
pain,  because  the  blood  will  flow  in  an  increased  quantity  to  a  part 
so  long  as  the  pain  continues.  It  being  impossible  to  prevent  it  by 
any  local  treatment  that  can  be  adopted,  you  may  give  McMunn's 
elixir  of  opium,  or  any  other  preparation,  either  alone  or  in  com- 
bination with  Hoffman's  anodyne. 

R.— Morph.  Sulph., gr.j. 

Sp.  Eth.  Co., •     gij. 

Syr.  Simplicis .     ^vj. 

M.  Sig.  Take  one  teaspoonful  every  hour  until  relieved. 

Sometimes  a  grain  of  old  opium,  or  a  fourth  of  a  grain  of  the 
sulphate  of  morphia,  may  be  given  every  hour  or  two  until  relief  is 
obtained.  The  quantity  of  opium  required  to  relieve  pain  depends 
upon  its  violence,  the  sex,  constitution,  and  habits  of  the  patient. 


LECTURE    XIX. — VARIETIES    OF    WOUNDS.  233 

In  one  case  the  eighth  of  a  grain  of  the  sulphate  of  morphia  will 
be  sufficient,  when  in  another  one  or  two  grains  could  be  taken 
with  impunity.  When  the  stomach  is  irritable,  it  may  be  either 
thrown  into  the  rectum  or  applied  endermically  or  hypodermically 
with  the  same  result.  The  only  modification  necessary  is  to  admin- 
ister by  enema  or  apply  to  a  denuded  surface  double  the  quantity 
proper  to  be  taken  into  the  stomach.  The  cuticle  may  be  removed 
in  a  few  minutes  by  the  application  of  three  or  four  doubles  of 
paper  wet  with  the  strongest  spirit  of  ammonia,  and  pressed  firmly 
to  the  part  so  that  the  air  may  be  entirely  excluded.  In  less  than 
five  minutes  the  cuticle  can  be  detached,  and  then  from  half  a  grain 
to  a  grain  of  the  sulphate  of  morphia  should  be  applied  and  retained 
with  a  small  portion  of  wet  printers7  paper,  which,  when  dry,  adheres 
more  firmly  than  adhesive  plaster.  When  a  considerable  quantity 
of  blood  is  effused,  you  should  allow  it  to  remain  for  a  time,  as  it 
may  be  absorbed.  Should  the  part,  however,  become  red  and  pain- 
ful, or  in  other  words  when  the  evidences  of  inflammation  and  sup- 
puration are  decided,  then  an  opening  should  be  made,  the  contents 
removed,  and  the  case  treated  as  an  ordinary  abscess.  The  wound 
made  to  empty  the  cavity  would  heal  by  the  first  intention  if  a  tent 
were  not  introduced  and  retained  for  twenty-four  hours,  then  it 
should  be  removed  and  the  warm-water  dressing  or  a  poultice 
applied  and  continued  until  the  discharge  ceases. 

Wounds  are  solutions  of  continuity  on  the  surface  of  the  body, 
produced  by  violence.  Some  authors  describe  four  varieties, — incised, 
contused,  punctured,  and  poisoned.  The  latter  will  be  considered 
separately,  and  as  the  wound  in  such  cases  constitutes  a  very  in- 
significant part  of  the  difficulty,  I  think  they  do  not  properly 
belong  to  this  class  of  injuries.  I  will  therefore  confine  my  remarks 
to  incised,  punctured,  and  contused  wounds.  The  first  are  made 
by  cutting  instruments.  If  I  were  to  draw  the  edge  of  a  knife 
across  the  back  of  my  hand,  an  incised  wound  would  be  the  result, 
and  it  would  be  serious  or  otherwise  in  proportion  to  its  depth. 
Should  the  skin  only  be  divided  it  would  be  considered  simple,  but 
should  it  be  sufficiently  deep  either  to  divide  the  tendons  or  to  open  a 
joint,  it  would  then  assume  a  very  different  character.  In  the  treat- 
ment of  incised  wounds  the  first  indication  is  to  arrest  the  hemor- 
rhage. Never  dress  a  wound  of  this  character  until  you  are  certain 
that  every  artery  has  been  ligated  or  that  the  bleeding  is  checked 


234  LECTURES    ON    PRACTICAL    SURGERY. 

by  other  means.  Never  trust  to  chance  or  pressure  in  such  cases. 
By  pursuing  this  course  I  have  never  had,  during  a  long  and  ex- 
tensive surgical  practice,  to  remove  the  dressings  but  once.  To  arrest 
a  haemorrhage  you  should  tie  every  vessel  of  sufficient  magnitude  to 
bleed,  particularly  if  you  desire  to  effect  union  by  the  first  intention. 
The  ligatures  should  be  placed  in  the  most  dependent  portion ;  they 
will  not  prevent  union,  except  at  the  point  they  occupy.  If  a 
tumor  be  removed,  never  try  to  heal  the  entire  wound  by  the  first 
intention,  because  such  efforts  are  always  unsuccessful.  If  few 
ligatures  have  been  applied,  then  a  small  portion  of  wet  lint  should 
be  introduced  to  enable  the  bloody  serum  and  purulent  secretion  to 
escape.  You  may,  by  pursuing  this  course,  prevent  pysemia,  which  is 
the  most  dangerous  complication  that  could  occur  after  either  the 
wound  or  surgical  operation.  When  the  haemorrhage  has  been  ar- 
rested, be  careful  to  remove  the  coagulated  blood  from  the  surfaces 
to  be  approximated,  for  if  it  is  allowed  to  remain  union  cannot  take 
place  by  the  first  intention. 

Wounds  also  differ  in  form,  which  depends  both  on  their  direction 
and  the  location  of  the  part  injured.  When  the  fibres  of  a  muscle  are 
divided  transversely,  the  space  that  intervenes  between  the  ex- 
tremities will  be  much  greater  than  if  the  incision  had  been  longi- 
tudinal, and  they  can  with  great  difficulty  be  approximated ;  and 
should  that  be  possible,  union  by  the  first  intention  will  not  occur, 
it  being  always  ligamentous.  Erichsen  thinks  that  wounds  may 
unite  by  five  different  processes.  The  first  he  calls  immediate 
union,  and  he  thinks  it  occurs  when  the  edges  of  a  wound,  after  the 
haemorrhage  is  arrested,  are  approximated  and  unite  without  the 
deposition  of  plastic  lymph.  I  cannot  conceive  of  the  possibility  of 
two  surfaces  uniting  without  the  intervention  of  lymph,  and  if  it  is 
possible,  you  will  find  that  it  is  a  very  rare  occurrence.  When  lymph 
constitutes  the  bond,  union  may  take  place  in  two  or  three  days,  or 
by  what  is  called  the  second  intention.  When  two  granulating 
surfaces  are  placed  and  retained  in  contact,  union  will  take  place  as 
readily  as  when  the  wound  was  inflicted.  I  have  recently  had  a 
case  in  which  an  epithelioma  of  the  lower  lip  was  removed.  The 
general  health  of  the  patient  being  greatly  impaired  by  intermittent 
fever,  at  the  expiration  of  five  days,  when  the  sutures  were  removed, 
union  had  not  taken  place.  The  wound  was  again  closed  by  the 
interrupted  silver  suture,  the  paroxysms  of  fever  were  arrested  by 


LECTURE    XIX. — PUNCTURED    WOUNDS.  235 

the  use  of  the  sulphate  of  quinine,  with  a  generous  diet  and  a 
bottle  of  porter  every  day ;  in  a  week,  union  by  the  second  in- 
tention had  taken  place,  and  was  as  perfect  as  if  it  had  occurred  as 
was  anticipated.  A  wound  may  heal  by  granulation  ;  when  the 
granulations  fill  the  wound,  cicatrization  occurs.  Epithelial  scales 
are  deposited  upon  the  surface  of  the  granulations  when  they  rise 
to  a  level  with  the  surrounding  integument.  The  skin  is  never 
reproduced,  consequently  a  cicatrix  never  resembles  it  in  any 
respect.  It  differs  in  color  and  appearance,  it  never  produces  hair, 
and  it  resembles  the  fibrous  more  than  the  cutaneous  tissue. 

The  difference  between  incised  and  punctured  wounds  is  that  the 
latter  are  more  extensive  in  depth  than  in  width,  and  an  incised 
wound  is  just  the  reverse.  Punctured  wounds  are  generally  made 
by  small  sharp-pointed  instruments,  yet  they  may  be  produced  by  a 
nail,  which,  when  sufficient  force  is  applied,  sometimes  passes 
through  the  integument,  and  you  then  have  both  a  punctured  and 
lacerated  wound,  which  is  more  dangerous  than  those  produced  by  a 
cutting  instrument,  and  require  different  treatment.  When  a  punc- 
tured wound  is  simple,  an  effort  should  be  made  to  heal  it  by  the 
first  intention  ;  when  deep,  place  a  compress  upon  each  side,  apply 
the  water-dressing,  and  secure  it  with  a  bandage  sufficiently  tight  to 
bring  the  entire  extent  of  the  surfaces  in  contact,  and  allow  it  to 
remain  until  union  has  taken  place.  Should  a  punctured  wound  be 
followed  by  hemorrhage  which  cannot  be  controlled  by  pressure, 
it  should  be  enlarged  and  the  vessel  ligated,  unless  it  be  one  of  the 
vessels  of  the  forearm  near  the  elbow-joint,  and  then  I  think  it 
would  be  better  to  apply  a  ligature  upon  the  brachial  artery.  Ten 
or  twelve  years  ago  a  gentleman  of  this  city  came  to  my  office  after 
having  suffered  from  repeated  attacks  of  haemorrhage,  which  re- 
sulted from  a  punctured  wound  made  by  a  sword-cane  that  was 
passed  through  the  upper  part  of  the  forearm  anterior  to  the  bones. 
The  wounds  were  small  and  painful,  and  being  greatly  exhausted 
by  the  loss  of  blood  he  was  placed  upon  a  sofa,  and  the  brachial 
artery  ligated,  because  he  had  no  more  blood  to  spare,  and  it  was 
impossible  to  determine  the  location  of  the  wounded  vessel.  The 
hemorrhage  did  not  return,  and  the  patient  was  well  in  fifteen  or 
twenty  days.  Whenever  one  of  the  arteries  near  the  wrist  is 
wounded,  it  is  always  better  to  enlarge  the  wound  and  apply  a 
ligature  both  above  and  below  the  puncture.  Should  inflammation 


236  LECTURES    ON    PRACTICAL    SURGERY. 

occur  after  such  an  injury,  it  should  be  treated  as  an  ordinary 
contusion,  and  when  suppuration  takes  place  an  incision  should  be 
made  and  the  water-dressing  applied.  Should  a  wound  be  both 
punctured  and  lacerated  or  contused,  never  allow  it  to  heal  by  the 
first  intention.  It  should  be  enlarged  if  made  by  a  nail,  par- 
ticularly if  upon  the  hands  or  feet,  and  filled  with  lint  saturated 
with  ol.  terebinthinse,  which  should  be  allowed  to  remain  until 
suppuration  is  established  ;  and  then  the  treatment  is  the  same  as 
that  of  an  ordinary  ulcer.  I  have  known,  both  here  and  elsewhere, 
persons  to  die  of  tetanus  in  consequence  of  a  different  course  being 
pursued. 

When  tetanus  does  follow  such  an  injury,  you  should  divide  the 
nerve  above  the  wound  if  possible.  Should  it  be  upon  the  foot  or 
hand,  make  a  crucial  incision  and  apply  the  actual  cautery  so  effec- 
tually as  to  cut  off  all  communication  with  the  brain.  A  few  years 
ago  I  published  two  cases  of  traumatic  tetanus  cured  by  a  surgical 
operation.  In  one  the  boy  was  saved  by  amputating  the  little  toe, 
and  in  the  other  by  making  a  transverse  incision  above  the  wound 
down  to  the  radius.  The  wounds  were  not  allowed  to  heal,  and  a 
grain  of  sulphate  of  morphia  was  applied  morning  and  evening,  and 
twenty  drops  of  the  tincture  of  cannabis  indica  was  given  every  two 
hours  until  the  symptoms  entirely  disappeared. 

I  have  now  under  treatment  a  man  from  Solano  County,  who  had 
tetanus  which  resulted  from  a  superficial  gunshot  wound  on  the  right 
side  of  the  abdomen.  One  grain  of  the  sulphate  of  morphia  was 
applied  every  six  hours,  and  twenty  drops  of  the  tincture  of  canna- 
bis indica  was  given  every  two  hours,  both  day  and  night.  He  im- 
proved so  rapidly  under  this  treatment,  that  the  wound  was  not 
removed  as  I  intended,  and  the  disease  in  two  weeks  was  entirely 
relieved,  except  a  slight  stiffness  or  contraction  of  the  muscles  of  the 
lower  jaw.  The  symptoms  in  such  cases,  if  the  disease  is  fully  de- 
veloped, do  not  disappear  so  soon  as  the  operation  is  performed,  but 
subside  gradually. 

Contused  wounds,  as  well  as  the  other  varieties,  vary  both  in  ex- 
tent and  degree.  The  contusion  may  be  slight  and  the  wound  very 
limited,  or  it  may  be  violent  and  the  solution  of  continuity  extensive, 
and  consequently  very  serious.  It  is  generally  believed  that  con- 
tused wounds  will  not  heal  by  the  first  intention.  I  have  treated 
two  gunshot  wounds  in  this  city,  in  which  a  pistol-ball  passed  through 


LECTURE    XIX. — CONTUSED    WOUNDS.  237 

the  anterior  and  muscular  part  of  the  thigh,  which  healed  in  less 
than  a  week  so  completely  that  both  the  patients  were  able  to  attend 
to  business,  although  one  of  them  was  brought  from  San  Mateo  in 
a  carriage  after  the  wound  was  inflicted.  The  only  remedy  employed 
was  cold-water  dressing,  and  the  same  result  was  obtained  in  both 
cases.  These  cases  are  exceptions  to  the  general  rule,  and  such  a 
course,  unless  in  the  same  or  some  other  equally  favorable  location, 
is  not  desirable.  You  will  frequently  meet  with  patients  who  suffer 
greatly  from  contused  wounds  of  the  scalp,  because  they  have  been 
improperly  treated,  either  by  the  interrupted  suture,  or  by  the  appli- 
cation of  adhesive  plaster.  In  such  cases,  after  the  blood  has  been 
removed,  wet  lint  should  be  placed  between  the  edges  of  the  wound, 
and  the  water-dressing  applied,  which  treatment  should  be  continued 
until  the  cavity  is  filled  by  granulations,  and  then  simple  cerate 
should  be  substituted. 

Contused  wounds  are  always  disposed  to  inflame,  and  should  the 
inflammation  be  so  violent  as  to  resist  the  action  of  the  remedies 
employed,  it  may  terminate  in  mortification.  Cold  irrigation  is 
superior  to  any  other  treatment  that  can  be  adopted,  and  the  mode 
of  application  depends  on  the  violence  of  the  injury.  You  may 
apply  lint,  wet  with  cold  water,  constantly  to  the  part,  or  suspend  a 
pitcher  or  any  other  conveniently  shaped  vessel,  with  candle  wicking 
so  arranged  as  to  act  as  a  siphon  and  convey  the  water  drop  by  drop 
where  it  is  required.  The  part  upon  which  the  water  falls  should 
be  covered  either  by  lint  or  by  three  or  four  folds  of  porous  cloth,  so 
as  to  protect  the  skin  from  its  direct  action.  The  quantity  of  water 
conveyed  to  the  part  inflamed  should  depend  upon  the  extent  and 
violence  of  the  inflammation,  and  can  be  increased  or  diminished  by 
changing  the  size  of  the  siphon. 

I  have  already  referred  to  the  extraordinary  effect  of  irrigation  in 
a  case  in  which  about  half  of  the  foot,  with  most  of  the  muscles  and 
tendons  of  the  leg,  were  torn  away  by  the  hawser  of  the  Oakland  ferry- 
boat, and  which  are  contained  in  this  jar.  That  man  was  able  to  walk 
in  six  weeks  almost  as  well  as  before  the  accident  occurred.  By  the 
influence  of  this  treatment,  at  the  expiration  of  nine  days,  every 
indication  of  inflammation  having  disappeared,  the  warm-water 
dressing  wras  applied,  and  so  soon  as  suppuration  was  established  the 
spiculse  of  bone  were  removed,  and  the  wound  speedily  cicatrized. 

I  repeat,  apply  cold  water  until  the  danger  of  inflammation  has 


238  LECTURES    ON    PRACTICAL    SURGERY. 

passed,  and  then  the  warm-water  dressing  or  poultices  to  hasten  the 
granulation  and  cicatrization  of  the  wound.  When  contused  wounds 
are  followed  by  excessive  inflammation  it  frequently  becomes  neces- 
sary to  resort  to  constitutional  treatment.  Formerly  bloodletting 
was  prescribed,  it  being  the  most  powerful  antiphlogistic  agent  known 
to  the  profession,  but  since  physicians  have  become  familiar  with  the 
properties  of  veratrum  viride,  aconite,  and  other  depressants,  it  is 
rarely  necessary  to  resort  to  venesection.  The  most  powerful  combi- 
nation of  depressants  I  have  ever  employed  was  given  in  my  lecture 
on  the  treatment  of  inflammation.  One  teaspoonful  of  that  mixture, 
given  every  two  hours,  will,  in  six  or  eight  hours,  control  the  most 
violent  arterial  action,  and  when  that  is  controlled  the  respiration 
and  temperature  become  normal,  the  secretions  are  restored,  and  con- 
sequently the  necessity  for  venesection  is  removed.  The  bowels 
should  be  kept  free  either  by  the  use  of  laxatives  or  by  the  occasional 
administration  of  an  enema.  During  the  continuance  of  inflamma- 
tion the  diet  should  be  low,  and  consist  of  arrowroot,  water-gruel, 
toast,  or  rice-water,  and  as  the  symptoms  improve  the  patient  should 
return  gradually  to  his  ordinary  diet. 

Gunshot  wounds  are  of  a  mixed  character,  being  usually  both 
punctured  and  contused.  When  an  ordinary  ball  passes  through  a 
part  it  produces  a  small  punctured  wound,  and  the  adjacent  parts 
are  violently  contused.  There  is  a  great  difference  in  size  between 
the  wounds  made  by  the  entrance  and  escape  of  the  ball,  the  former 
being  always  much  smaller  and  less  irregular,  although  that  depends 
somewhat  on  the  velocity.  If  a  gun  is  well  charged  and  placed  near 
the  part  the  ball  will  pass  through  with  great  velocity,  and  the  dif- 
ference in  the  size  of  the  wounds  will  be  much  less  than  if  the  object 
were  at  a  greater  distance.  Consequently  the  velocity  of  a  ball  can 
generally  be  determined  by  the  difference  in  the  size  of  the  wounds. 

Gunshot  wounds  always  excite  great  alarm,  and  produce  more 
constitutional  disturbance  than  any  other  injury.  Even  if  the  wound 
be  very  slight,  a  mere  superficial  abrasion,  it  usually  is  so  depressing 
that  the  skin  becomes  pale  and  cold,  the  breathing  difficult,  and  the 
pulse  small  and  frequent.  In  such  a  case  you  must  encourage  the 
patient  by  speaking  kindly  and  cheerfully,  and  administer  stimu- 
lants to  promote  reaction,  which  will  soon  occur  if  the  injury  is 
slight ;  but  should  an  extremity  be  torn  off  or  shattered  by  a  cannon- 
ball,  the  prostration  would  be  so  great  that  reaction  would  take 


LECTURE    XIX.  —  GUNSHOT    WOUNDS.  239 

place,  if  at  all,  very  slowly,  and  the  patient  would  perish  from  the 
nervous  shock,  inseparable  from  such  an  injury.  Should  an  extremity 
be  torn  away  by  a  cannon-ball,  the  skin  is  always  shorter  than  the 
muscles,  is  above  the  exposed  surface,  and  the  bone  and  muscles 
project,  and  the  latter  present  a  red  and  ragged  appearance. 

It  is  not  necessary  that  firearms  should  contain  a  ball  to  inflict  a 
serious  wound.  It  may  result  either  from  powder  alone,  from  a  wad 
of  tow  or  paper,  a  splinter  of  wood,  or  any  solid  substance.  It  is 
more  important  to  know  how  to  treat  a  gunshot  wound  than  to  ascer- 
tain how  it  was  produced.  The  inflammation  which  follows  a  wound 
of  this  character  either  terminates  in  mortification,  or  suppuration  is 
soon  established.  The  edges  frequently  slough,  although  this  does 
not  necessarily  occur.  All  foreign  bodies  should,  if  possible,  be 
removed,  and  the  surfaces  placed  as  nearly  in  contact  as  possible,  and 
then  cold  applications  made,  as  already  recommended,  to  limit  the 
extent  and  moderate  the  violence  of  the  inflammation.  When  that 
has  subsided,  or  the  period  for  its  development  has  passed,  warm 
applications  should  be  made  for  the  purpose  of  hastening  both  the 
separation  of  the  slough  and  the  production  of  healthy  granulations, 
so  that  the  opposing  surfaces  of  the  wound  may  be  approximated 
and  retained  in  contact  until  union  takes  place. 


240          LECTURES  ON  PRACTICAL  SURGERY. 

L  I  UK  A  iv  i 


JNIYEUSITY  OF 

CALIFORNIA. 


LECTURE   XX. 


GENTLEMEN  :  My  last  lecture  was  upon  wounds  and  contusions. 
I  then  told  you  that  the  former  include  incised,  punctured,  and 
contused  or  lacerated  wounds,  and  also  endeavored  to  describe 
gunshot  wounds,  which  is  rather  difficult,  as  they  may  result  from 
powder,  from  a  wad  either  of  tow  or  paper,  from  small  shot,  buck- 
shot, a  minie  or  common  ball,  a  portion  of  an  exploded  shell,  a 
splinter  of  wood,  or  any  solid  substance  which  can  be  thrown  with 
sufficient  force  by  powder  to  produce  a  contused  or  lacerated  wound. 
In  every  case  of  this  character  the  first  indication  in  the  local  treat- 
ment is  to  extract  the  ball  or  other  foreign  substance  if  possible. 
Various  instruments  are  used  for  that  purpose.  The  ordinary  dressing 
forceps  is  in  many  cases  as  convenient  as  any  instrument  that  can  be 
employed.  The  bullet  forceps  which  I  exhibit  are  generally  used 
in  deep  narrow  wounds,  there  being  a  cavity  in  the  extremity  of 
each  blade  which  renders  them  superior  to  the  dressing  forceps, 
particularly  if  the  ball  be  round  and  smooth.  The  best  instrument 
for  this  purpose  is  the  one  which  I  now  exhibit.  When  the  position 
of  the  ball  is  ascertained,  it  can  be  secured  by  the  screw  on  the  ex- 
tremity of  the  instrument  and  removed  as  you  would  draw  a  cork  from 
a  bottle.  Even  with  such  instruments  at  your  command,  you  will  find 
it  exceedingly  difficult  in  deep  and  narrow  wounds  to  remove  either 
a  ball  or  any  other  foreign  substance.  After  two  or  three  unsuccessful 
efforts  have  been  made,  it  is  better  not  to  distress  the  patient,  but 
to  leave  it  in  the  wound  either  to  be  thrown  off  by  suppuration  or 
to  become  encysted,  when  it  will  no  longer  prove  a  source  of  irri- 
tation. I  treated  a  case  in  the  County  Hospital  thirteen  years  ago, 
in  which  the  contents  of  a  large  duck-gun  were  received  in  the 
upper  and  external  portion  of  the  thigh.  The  shot  were  so  numer- 
ous that  I  determined  to  allow  them  to  remain  until  suppuration 
took  place,  and  then  be  governed  by  circumstances.  In  two  or  three 
weeks  the  shot  were  all  removed  without  pain,  nor  was  the  convales- 
cence of  the  patient  retarded.  Should  the  wound,  however,  be  large, 
and  if  the  foreign  substance  can  be  exposed  and  removed  without 


LECTURE  XX. — GUNSHOT  WOUNDS.  241 

difficulty,  it  should  not  be  neglected.  Should  haemorrhage  follow  an 
operation  of  this  character,  it  should  be  arrested  and  the  wound  then 
treated  as  already  indicated.  In  such  cases  you  can  neither  apply 
evaporating  nor  anodyne  lotions,  because  there  is  a  solution  of 
continuity ;  such  remedies  are  not  only  painful,  but  if  long  con- 
tinued will  produce  inflammation  of  the  wound.  The  best  possible 
application  is  cold  water ;  if  the  wound  be  slight,  four  or  five  layers 
of  porous  cloth  or  lint  kept  constantly  wet  is  all  that  is  required. 
In  more  serious  cases,  where  violent  inflammation  and  extensive 
sloughing  is  dreaded,  cold  irrigation  should  be  preferred,  and  by  its 
faithful  employment  I  believe  that  you  can  often  save  not  only  an 
extremity  but  also  a  valuable  life,  when  by  other  treatment  they 
would  be  sacrificed.  I  shall  always  recollect  the  case  of  a  distin- 
guished lawyer  of  this  city,  who  jumped  from  a  buggy  when  in 
rapid  motion,  and  struck  upon  the  outer  side  of  the  right  foot.  He 
dislocated  the  ankle-joint,  and  the  lower  extremity  of  the  fibula  pro- 
truded through  a  wound  three  inches  in  length.  After  the  reduction 
of  the  dislocation,  the  limb  was  placed  upon  Roe's  splint,  which  had 
been  previously  well  padded  with  cotton.  It  was  kept  wet  constantly 
for  ten  days,  and  then  the  warm-water  dressing  was  substituted,  and 
in  forty-six  days  he  was  able  to  visit  a  neighboring  city  to  attend  ta 
an  important  case  in  which  he  was  interested,  before  the  Supreme 
Court  of  this  State.  Cases  resulting  from  gunshot  wounds,  as  well 
as  other  injuries,  occasionally  occur  in  which  it  is  impossible  to  save 
the  limb  by  any  course  of  treatment  that  can  be  adopted.  Suppose 
that  an  arm  or  leg  should  be  shattered  by  a  spent  cannon-ball  or  by 
the  falling  of  a  heavy  weight,  by  which  both  the  bones  and  the 
bloodvessels  are  injured,  and  the  patient  exposed  to  the  danger  of 
secondary  haemorrhage,  then  it  would  be  unsafe  to  make  the  effort. 

Should  the  capsular  ligament  of  the  knee  be  injured,  the  bones- 
fractured,  and  the  artery  wounded,  then  you  should  not  hesitate  to- 
amputate  the  limb.  Very  frequently  when  the  ankle-joint  is  ex- 
posed, the  patient,  as  you  have  already  been  told,  may  recover,  and 
the  members  of  the  class  who  have  attended  my  clinical  lectures  have 
had  an  opportunity  to  know  the  treatment  which  I  prefer  in  gunshot 
wounds  of  the  hand.  It  so  happened  that  two  unfortunate  young  men 
were  admitted  in  almost  the  same  condition.  In  both  cases  the  thumb 
and  little  finger  were  all  that  remained,  and  instead  of  amputating  at 
the  wrist  they  were  saved  in  both  cases.  You  should  always  remove  the 

16 


242  LECTURES    ON    PRACTICAL    SURGERY. 

shattered  bones,  the  lacerated  tendons,  nerves,  and  muscles,  and  en- 
deavor to  save  integument  enough  to  cover  and  protect  the  parts 
that  are  preserved.  When  an  extremity  is  crushed,  or,  in  other 
words,  when  all  the  bones,  nerves,  and  tendons  are  mangled,  as 
occurred  some  years  ago  in  the  case  of  a  boy  twelve  years  old,  whose 
hand  was  caught  by  the  beater  of  a  cotton  mill  and  torn  in  pieces, 
I  did  not  hesitate  to  remove  it,  although  the  operation  was  per- 
formed with  a  shoemaker's  knife  and  a  tenon  saw.  I  never  per- 
formed one  that  resulted  so  favorably.  The  wound  healed  entirely 
by  the  first  intention,  and  the  boy  in  less  than  a  week  was  able  to 
resume  his  position. 

Some  difference  of  opinion  exists  in  reference  to  the  time  at  which 
amputation  should  be  performed.  After  a  severe  shock  there  is 
always  great  prostration,  which  continues  from  one  to  six  hours,  ac- 
cording to  the  extent  and  violence  of  the  injury.  When  reaction 
does  not  take  place  within  the  time  specified,  there  is  great  danger 
that  it  will  not  occur;  the  injury  may  be  so  serious  that  it  is  impos- 
sible for  the  system  to  react,  and  hence,  if  at  the  expiration  of  six 
hours  the  temperature  of  the  body  is  not  restored,  the  pulse  has  not 
become  full  and  strong,  and  the  mental  faculties  are  still  impaired, 
you  should  apprehend  the  most  serious  consequences.  When  reac- 
tion does  occur,  twenty-four  hours  generally  elapse  before  any  decid- 
edly unfavorable  symptoms  appear,  and  inflammation  is  then  usually 
developed,  which  may  be  so  violent  as  to  terminate  in  gangrene,  but 
if  controlled  suppuration  will  soon  be  established,  accompanied  with 
fever,  which  generally  continues  until  the  patient  recovers  or  dies 
from  exhaustion. 

You  will  frequently,  both  in  gunshot  wounds  and  other  serious 
injuries,  find  that  the  case  will  progress  favorably  for  some  time 
after  suppuration  is  established,  and  then  the  patient  is  attacked 
suddenly  with  diarrhea,  his  appetite  is  impaired,  the  strength 
rapidly  diminishes,  and  unless  the  cause  is  removed  a  fatal  result  is 
inevitable.  In  such  cases  amputate,  and  then  give  tonics  and  stim- 
ulants with  as  much  simple  nutritious  food  as  can  be  digested,  and 
the  result  will  almost  always  be  favorable.  Patients  recover  more 
speedily  and  certainly  from  amputations  after  they  have  become 
inured  to  pain  and  an  exhausting  purulent  discharge,  than  if  they 
had  been  operated  on  at  an  earlier  period,  except  within  a  few  hours 
after  the  receipt  of  the  injury.  I  would  therefore  advise  you 


LECTURE    XX.  —  TREATMENT    OF    WOUNDS.  243 

always  to  operate  during  the  second  or  fourth  stages.  Never  ampu- 
tate during  the  stage  of  depression  nor  during  the  existence  of  acute 
inflammation.  The  best  time  is  so  soon  as  reaction  occurs,  and 
should  circumstances  render  this  impossible,  then  it  should  be  deferred 
until  suppuration  is  fully  established.  Be  careful  to  subject  the  patient 
to  as  little  pain  as  possible;  take  every  precaution  to  prevent  exces- 
sive hemorrhage,  and  you  will  succeed  even  under  very  unfavorable 
circumstances.  I  have  been  practicing  surgery  for  thirty  years,  and 
yet  I  have  neither  lost  a  patient  on  the  table  nor  within  five  days 
after  the  operation  was  performed.  You  often  hear  of  patients  dying 
either  on  the  table  or  within  a  few  hours  after  they  have  been  re- 
moved. I  think  that  in  such  cases  there  has  been  bad  management. 
They  have  inhaled  too  much  chloroform,  have  lost  too  much  blood, 
or  were  not  in  a  condition  to  submit  to  such  an  operation.  When  I 
dread  the  consequences  from  the  loss  of  blood  in  an  operation,  I 
supply  three  or  four  young  men  with  spring  forceps  enough  to  seize 
all  the  large  vessels  and  secure  them  until  ligatures  can  be  applied. 
When  this  course  is  pursued  there  is  no  necessity  for  the  loss  of  much 
blood,  even  in  the  most  extensive  operation.  During  the  inflam- 
matory stage  the  patient  should  be  kept  quiet,  and  the  best  means, 
both  general  and  local,  employed  to  limit  its  extent  and  diminish  its 
violence.  No  operation  should  be  performed  during  that  period,  as 
it  would  be  exceedingly  dangerous.  I  repeat,  that  the  consequences 
that  may  result  from  the  inflammation  that  must  follow  every  serious 
injury,  should  be  ascertained  before  an  operation  is  either  recom- 
mended or  performed. 

When  mortification  follows  either  a  gunshot  wound  or  any  other 
serious  injury,  always  wait  until  you  are  certain  that  the  difficulty 
is  arrested,  which  can  only  be  positively  determined  when  the  line 
of  demarcation  is  distinct  and  decided,  and  then  the  operation  will 
not  have  to  be  repeated.  In  the  case  operated  upon  in  the  hospital 
for  popliteal  aneurism,  in  consequence  of  the  condition  of  the  pa- 
tient, gangrene  of  the  limb  occurred  eight  days  after  the  femoral 
artery  was  ligated.  The  parts  below  the  ligature  were  not  alone 
implicated,  but  mortification  extended  to  the  hip-joint,  and  if  am- 
putation of  the  thigh  had  been  performed,  it  would  have  failed  to 
save  the  patient.  It  is  therefore  always  better  to  wait  until  the  line 
of  demarcation  is  distinct,  because  if  you  operate  before  that  occurs 
the  stump  may  become  gangrenous,  and  you  should  always  allow 


244  LECTURES    ON    PRACTICAL    SURGERY. 

a  patient  to  die  from  the  consequences  of  the  injury  rather  than  for 
the  result  to  be  attributed  to  the  interference  of  the  surgeon.  In 
such  cases  always  advise  with  one  or  two  medical  friends,  as  a  young 
physician  cannot  be  too  careful  of  his  reputation. 

Heat  and  Cold. — It  is  exceedingly  important  to  be  familiar  with 
the  effect  of  excessive  cold  and  heat  upon  the  human  body.  Cold 
diminishes  the  vitality,  and  if  frequently  repeated  or  too  long  con- 
tinued, produces  inflammation  of  the  part  exposed,  which  is  generally 
confined  to  the  skin  covering  the  extremities,  and  is  called  chilblains. 
Delicate  persons  are  more  liable  to  this  disease  than  the  robust  and 
vigorous,  and  in  such  constitutions  it  is  not  necessary  that  the  ex- 
posure be  long  continued  or  very  intense.  You  will  meet  with  many 
persons  in  this  city  with  chilblains,  although  the  weather  is  seldom 
cold.  The  part  becomes  red  and  swollen,  and  itches  or  burns  ex- 
cessively. The  feet  are  more  liable  to  the  disease,  although  the 
fingers  suffer  occasionally.  At  one  time  I  showered  my  feet  at 
night  to  remove  the  heat  and  soreness  resulting  from  close  attention 
to  business,  and  in  about  two  weeks  I  had  chilblains  so  severely 
that  the  cold  water  had  to  be  abandoned.  The  feet  were  then  showered 
with  warm  water  until  the  skin  became  very  red,  and  after  being 
dried  perfectly  with  a  coarse  towel,  were  kept  warm  during  the 
night  by  the  application  of  a  heated  brick  or  a  bottle  filled  with 
hot  water,  which  very  soon  removed  the  difficulty. 

Chilblains  require  different  treatment  from  that  pursued  in  other 
forms  of  inflammation;  besides  the  remedy  already  mentioned, 
apply  camphorated  oil,  ol.  terebinthinse,  equal  parts  of  spts.  vin. 
rectif.  and  tinct.  arnicre,  or  the  tinct.  of  iodine  and  arnica. 
In  cold  climates  this  condition  is  exceedingly  common,  very 
annoying,  and  difficult  to  cure,  but  in  California  the  course  of  treat- 
ment indicated  will  generally  soon  afford  relief.  When  the  cold  is 
more  intense  the  vitality  of  the  part  is  destroyed,  and  it  is  said  to  be 
frostbitten.  If  any  portion  of  the  human  body  be  exposed  for  half 
an  hour,  when  the  thermometer  is  ten  or  fifteen  degrees  below  zero, 
it  will  freeze.  I  recollect  that  when  I  was  a  student  in  Kentucky,  I 
walked  about  half  a  mile  on  such  a  night,  and  found  when  I  reached 
home  that  the  ear  which  had  been  exposed  to  the  north  wind  was 
frozen.  For  a  short  time  after  leaving  the  college  the  ear  was  quite 
painful,  but  very  soon  the  sensibility  was  destroyed,  and  I  became 
aware  of  the  fact  only  by  the  sense  of  touch.  Snow  was  applied  and 


LECTURE    XX.  —  BURNS.  245 

retained  by  the  hand  until  it  melted,  then  a  cloth  wet  with  cold 
water  was  substituted,  and  continued  until  the  sensibility  was 
restored.  By  pursuing  that  course,  or,  in  other  words,  by  thawing 
the  part  gradually,  the  inflammation  will  be  much  less  violent. 
Intense  cold  has  the  effect  to  darken  the  skin  much  more  rapidly 
than  heat.  A  few  years  since,  a  party  of  gentlemen  of  this  city 
returned  from  Salt  Lake,  in  winter,  and  when  they  reached  San 
Francisco,  although  they  were  well  protected,  the  skin  on  the  face 
was  darker  than  that  of  a  mulatto,  but  subsequently  the  cuticle 
was  detached  and  the  natural  color  restored.  The  treatment  already 
given  is  that  which  experience  has  proved  most  successful.  After 
the  rigidity  of  the  part  has  been  removed,  cotton  batting  should  be 
applied,  and  secured  until  inflammation  supervenes.  When  the  part 
has  not  been  exposed  too  long  and  has  been  properly  treated,  the 
swelling  is  not  usually  very  great,  and  in  a  few  days  the  cuticle  is 
detached,  and  the  part  restored  to  a  healthy  condition. 

In  cold  climates  many  die  from  exposure,  but  more  lose  a  portion 
of  the  extremities.  If  heat  be  applied  so  soon  as  the  difficulty  is 
discovered,  and  reaction  takes  place  at  all,  sufficient  inflammation 
will  follow  to  destroy  the  vitality  of  the  part.  The  boy  upon  whom 
I  performed  Pirogoff's  operation  on  both  feet,  was  rendered  a 
cripple  in  both  his  hands  and  feet  by  exposure  in  the  mountains  of 
California.  The  sensibility  of  the  feet  was  so  much  diminished  that 
he  refused  to  take  chloroform,  and  suffered  but  little  from  either 
operation.  Should  mortification  result  from  this  cause,  you  should 
wait  not  only  until  the  line  of  demarcation  is  distinct,  but  also 
until  the  separation  of  the  dead  from  the  living  tissues  is  complete, 
and  then  the  bones  can  easily  be  divided.  The  wound  should  be 
treated  as  one  resulting  from  any  other  cause. 

Burns. — When  a  part  is  exposed  to  a  high  degree  of  temperature 
the  action  is  increased.  It  becomes  red  in  consequence  of  the  dis- 
tension of  the  vessels,  and  if  the  heat  be  sufficient  to  derange  the 
ordinary  and  healthy  action  it  is  called  a  burn.  These  may  be 
divided  into  three  varieties,  or  rather  there  are  three  degrees  of 
diseased  action  resulting  from  the  application  of  heat. 

The  first  is  indicated  by  increased  redness  of  the  skin,  accompanied 
with  pain.  The  danger  to  be  apprehended  from  a  burn  does  not 
depend  upon  its  degree  but  upon  its  extent.  A  mere  redness  of  an 
extensive  surface  produces  more  constitutional  disturbance  and  is 


246  LECTURES    ON    PRACTICAL    SURGERY. 

more  dangerous  than  a  much  deeper  lesion  that  is  not  extensive. 
When  I  was  in  the  Hotel  Dieu  in  Paris  one  of  the  nurses  in  the 
hospital  died,  in  consequence  of  taking  a  bath  so  hot  as  to  scald  or 
redden  the  skin,  but  not  sufficiently  so  to  produce  the  slightest 
vesication.  Whenever  you  are  required  to  treat  a  burn,  let  it  be 
ever  so  slight,  if  extensive  you  should  always  be  careful  in  mak- 
ing a  prognosis.  Extensive  burns  are  almost  always  fatal.  They 
destroy  the  function  of  the  skin,  fever  from  irritation,  accompanied 
with  diarrhoea,  soon  appears  and  continues  until  it  proves  fatal.  As 
I  have  already  remarked,  in  a  burn  of  the  first  degree  there  is 
merely  a  redness  of  the  skin,  but  when  a  part  is  either  subjected  to 
greater  heat  or  kept  longer  under  its  influence  the  skin  not  only 
becomes  red,  but  serum  is  secreted,  which  detaches  the  cuticle  and 
produces  what  is  called  vesication,  and  a  burn  of  the  second  degree, 
which,  like  the  first  variety  described,  is  dangerous  in  proportion  to 
its  extent. 

In  a  burn  of  the  third  degree,  the  true  skin  is  destroyed  with  or 
without  the  subjacent  parts.  Sometimes  not  only  the  skin,  but  the 
tendons,  muscles,  and  even  the  bones  are  destroyed. 

I  recollect  two  cases  which  were  produced  in  the  same  manner 
that  were  treated  in  the  Hotel  Dieu.  The  patients  were  both 
females  about  sixteen  years  old,  and  in  consequence  of  some  disap- 
pointment attempted  to  commit  suicide  by  inhaling  carbonic  acid  gas 
generated  by  burning  charcoal.  When  rendered  insensible,  and 
during  the  struggle  inseparable  from  such  a  condition,  the  anterior 
portion  of  the  right  leg  came  in  contact  with  the  grate  which  con- 
tained the  burning  charcoal.  Although  they  both  failed  to  destroy 
life,  they  succeeded  in  destroying  the  parts  which  covered  the  tibia 
about  two-thirds  of  its  length,  and  the  periosteum  of  more  than  half 
of  the  thickness  of  that  bone.  When  I  left  Paris  they  were  both  in 
good  health  and  very  cheerful  and  comfortable,  and  although  a  year 
had  elapsed,  there  was  no  evidence  that  the  dead  bone  would  be 
speedily  detached,  which  was  indispensable  before  the  wounds  could 
cicatrize. 

When  a  burn  is  produced  by  either  hot  or  boiling  liquid  it  is 
called  a  scald,  which  produces  the  same  effect  as  dry  heat,  and  the 
same  extent  of  injury  may  result  from  the  application.  There  may 
be  an  unnatural  redness  of  the  skin,  vesication,  and  an  entire  destruc- 
tion of  the  tissues,  arid  this  requires  the  same  treatment. 


LECTURE    XX.  —  BURNS.  247 

Treatment. — When  a  burn  is  slight  and  not  too  extensive,  the 
best  remedy  is  to  hold  the  part  as  near  a  fire  as  possible,  and  retain 
it  in  that  position,  however  painful,  at  least  half  an  hour;  by  the 
expiration  of  that  time  the  redness  will  have  entirely  disappeared. 
Even  when  the  skin  is  so  much  burned  as  to  vesicate,  if  heat  is 
properly  applied,  the  same  salutary  influence  may  be  expected. 
Some  years  ago  the  child  of  a  personal  friend  ran  into  his  bedroom 
at  night  with  the  posterior  portion  of  her  dress  in  a  blaze ;  he 
caught  the  burning  clothes  in  his  hand  and  directed  his  wife  to  ex- 
tinguish the  flames  by  the  application  of  water.  The  child  was  not 
injured,  but  both  of  his  hands  were  extensively  vesicated.  Being 
very  much  engaged  in  business  I  directed  him  to  hold  his  hands 
in  front  of  the  grate  and  as  near  as  possible  until  the  blisters  dis- 
appeared, regardless  of  the  pain  that  might  result.  The  next  morn- 
ing the  hands  were  neither  vesicated  nor  painful ;  the  cuticle  was 
gradually  detached  without  giving  the  patient  the  slightest  incon- 
venience. There  is  no  doubt  that  when  patients  will  bear  the  pain, 
even  in  burns  of  the  second  degree,  the  proper  application  of  heat 
will  cause  an  absorption  of  the  serum,  the  skin  will  not  inflame, 
and  the  detached  cuticle  will  remain  and  protect  it  until  another 
is  produced.  The  heat  enables  the  vessels  to  relieve  themselves  of 
the  unnatural  quantity  of  blood  invited  there  by  the  irritation.  The 
same  course  of  treatment  is  equally  beneficial  in  the  obstinate  ulcera- 
tion  of  the  hands  so  common  in  California,  two  or  three  applica- 
tions being  usually  sufficient.  When  a  burn  is  both  severe  and 
extensive,  and  particularly  when  the  treatment  proposed  is  rejected, 
other  means  should  be  adopted.  It  is  universally  acknowledged 
that  the  best  local  application  is  a  mixture  composed  of  equal  parts 
of  ol.  olivae  and  aqua  calcis.  They  form  a  whitish  semifluid  com- 
pound which  may  be  applied  either  with  a  feather  or  a  camePs-hair 
pencil  so  as  to  cover  the  entire  surface.  It  not  only  allays  irrita- 
tion but  also  protects  the  part  from  the  action  of  the  atmosphere. 
Cotton  batting  should  then  be  applied  and  secured  by  a  roller  ban- 
dage. The  dressing  should  not  be  removed  for  three  or  four  days 
unless  it  has  been  accidentally  disturbed,  and  then  it  can  be  changed 
without  the  slightest  difficulty,  in  consequence  of  suppuration  being 
established.  When  the  first  dressing  is  removed,  if  the  surface  be 
found  dry,  inflamed,  and  painful,  I  have  found  a  slippery  elm  or 
flaxseed  poultice,  made  thin  and  covered  with  oiled  silk,  an  exceed- 


248  LECTURES    ON    PRACTICAL    SURGERY. 

ingly  useful  application.  The  warm- water  dressing,  when  the  burn 
is  extensive,  is  much  more  convenient  and  less  distressing  by  its 
weight,  and  should  be  preferred.  This  treatment  should  be  con- 
tinued until  suppuration  is  established  and  the  pain  has  entirely 
disappeared.  To  hasten  the  cicatrization  of  such  a  wound  I  have 
found  an  ointment  composed  of  creta  prep.  5ij  to  5j  of  hog's  lard 
superior  to  any  other  application.  The  subnitrate  of  bismuth  in  the 
same  proportions  will,  in  some  cases,  be  found  exceedingly  useful. 

Besides  the  local  remedies  recommended,  you  will  find  it  necessary 
to  prescribe  constitutional  treatment  during  the  inflammatory  stage, 
and  so  long  as  the  febrile  symptoms  continue,  depressants  should  be 
administered  to  diminish  arterial  action,  accompanied  with  an  anti- 
phlogistic regimen  and  laxatives  if  necessary.  When  suppuration  is 
established,  if  the  secretion  be  profuse,  then  stimulants  and  tonics, 
with  a  generous  diet,  should  be  substituted.  To  adults  give  quinise 
sulph.  two  grains,  four  times  a  day,  with  either  brandy  or  good  port 
or  sherry  wine,  according  to  the  condition  and  previous  habits  of  the 
patient. 

For  women  or  children  the  best  stimulant  is  California  port  wine. 
They  take  it  willingly  because  it  is  pleasant  to  the  taste,  and  I 
have  found  it,  from  extensive  experience  in  cases  of  this  character, 
as  well  as  in  typhoid  and  scarlet  fevers,  after  the  acute  stage  has 
passed,  one  of  the  most  valuable  stimulants  that  can  be  administered. 
Without  opium  to  relieve  pain  and  produce  sleep,  no  case  can  be 
treated  properly.  It  should  be  given  every  night  in  a  sufficient 
quantity  to  produce  that  effect. 


LECTURE    XXI.  —  POISONS.  249 


LECTURE   XXI. 

GENTLEMEN  :  This  morning  I  propose  to  say  a  few  words  about 
poisons.  These  are  substances  which  destroy  the  structure  or  de- 
range the  action  of  the  body,  independently  of  mechanical  violence 
or  increase  of  temperature.  Those  which  destroy  the  structure,  are 
mineral  acids,  corrosive  sublimate,  nitrate  of  silver,  and  caustic 
potash.  The  latter,  when  applied  to  the  skin,  will  destroy  it  in  one 
or  two  hours.  Although  its  action  is  prompt  and  powerful,  you  will 
sometimes  find  it  exceedingly  valuable  in  the  practice  of  surgery. 
Suppose  you  should  find  it  necessary  to  open  an  abscess  of  the  liver, 
and  no  positive  evidence  existed  that  adhesion  had  taken  place 
between  the  diseased  organ  and  the  abdominal  parietes,  then  the 
caustic  potash  is  invaluable,  as  by  its  use  adhesive  inflammation  can 
be  produced,  and  a  sufficient  opening  made  to  allow  the  matter  to 
escape ;  otherwise,  the  contents  of  the  abscess  would  pass  into  the 
cavity  of  the  peritoneum  and  prove  fatal.  In  such  cases,  apply  one 
grain  over  the  most  prominent  part  of  the  tumor,  cover  it  with  ad- 
hesive plaster,  and  in  two  or  three  hours  after  it  ceases  to  be  painful, 
raise  with  a  tenaculum  the  insensible  and  discolored  portion  of  the 
integument,  and  remove  it  with  a  scalpel.  One  grain  will  destroy  the 
skin  and  subcutaneous  cellular  tissue.  Two  grains  should  then  be 
placed  and  confined  in  the  cavity  produced  by  the  first  application, 
which  will  be  sufficient  to  extend  to  the  peritoneum,  and  cause  that 
membrane  to  unite  with  the  portion  covering  the  external  surface 
of  the  tumor.  In  three  or  four  days,  if  the  contents  do  not  escape, 
a  trocar  or  bistoury  should  be  introduced.  Some  months  since,  I 
was  requested  to  see  a  patient  who  had  been  spending  some  time  in 
the  tropics,  and  was  suffering  from  great  enlargement  of  the  epi- 
gastric region.  Although  the  symptoms  were  very  unpromising,  I 
determined  to  apply  the  caustic,  as  described,  and  in  two  days  after 
the  second  application  a  bistoury  was  introduced,  and  an  immense 
quantity  of  matter  liberated.  Although  temporarily  relieved,  his 
pulse  continued  to  beat  as  rapidly  as  before,  and  he  died  from  ex- 
haustion in  about  three  weeks.  It  was  ascertained  by  a  post-mortem 


250          LECTURES  ON  PRACTICAL  SURGERY. 

examination  that  the  abscess  communicated  both  with  the  stomach 
and  pericardium,  which  accounted  for  the  excessive  frequency  of  the 
pulse  and  the  obstinacy  of  the  other  symptoms.  When  a  mineral 
acid  is  applied  either  to  the  skin  or  mucous  membrane,  if  not 
speedily  removed  or  neutralized,  the  vitality  will  soon  be  destroyed  ; 
and  this  is  more  or  less  serious  in  proportion  to  the  extent  and 
locality.  Several  children  have  died  in  this  city  by  drinking  sul- 
phuric acid  by  mistake  for  soda  water.  In  such  cases  there  is  usually 
an  entire  destruction  of  the  mucous  membrane,  which,  if  not  speedily 
fatal,  must  be  followed  by  stricture  of  the  oesophagus,  which  sooner 
or  later  destroys  the  patient.  In  such  cases,  a  solution  of  the  super- 
carbonate  of  soda,  or  subcarbonate  of  potash,  should  be  administered 
as  soon  as  possible,  and  continued  until  the  acid  is  neutralized  ;  then 
the  case  should  be  treated  according  to  the  symptoms.  Should  a 
sufficient  quantity  of  corrosive  sublimate  be  taken  into  the  stomach 
to  destroy  life,  an  emetic  of  sulphate  of  zinc,  5j  dissolved  in  half 
a  tumbler  of  water,  should  be  administered,  and  repeated  every 
fifteen  minutes  until  vomiting  is  produced.  The  action  of  the 
emetic  can  be  rendered  more  prompt  either  by  passing  a  feather 
into  the  pharynx,  or  by  tickling  the  uvula  and  posterior  portion  of 
the  fauces  with  the  finger.  Some  years  since,  I  was  called  late  at 
night  to  see  a  woman  who  had  taken  an  ounce  of  laudanum.  Not 
having  a  stomach-pump  at  my  residence,  I  went  prepared  with  an 
emetic,  but  finding  it  impossible  to  induce  her  to  take  it,  and  the 
jaw  teeth  on  one  side  being  absent,  I  passed  the  forefinger  into  the 
mouth  until  the  extremity  rested  upon  the  uvula,  and  kept  it  in  that 
position  until  the  contents  of  the  stomach  were  expelled.  When  an 
emetic  will  not  act,  and  a  stomach-pump  can  be  obtained,  the  con- 
tents of  that  organ  should  be  diluted  with  warm  water  and  removed 
as  speedily  as  possible,  and  then  the  stomach  should  be  filled  with 
mucilaginous  or  demulcent  solutions.  The  white  or  albuminous 
part  of  eggs,  combined  with  water,  should  be  preferred,  but  if  they 
cannot  be  obtained,  a  solution  of  gum  arabic  or  flaxseed  may  be 
substituted. 

Although  great  injury  has  resulted  from  the  improper  use  of 
nitrate  of  silver,  yet  we  are  rarely  required  to  treat  a  case  of 
poisoning  resulting  from  this  cause  ;  yet,  if  such  a  case  should  occur, 
a  solution  of  common  salt  is  the  best  antidote  that  can  be  admin- 
istered. To  limit  the  action  of  the  nitrate  of  silver,  when  applied 


LECTURE    XXI.  —  POISONS.  251 

to  granulated  lids,  a  weak  solution  of  common  salt  is  superior  to 
any  application  that  can  be  made. 

The  use  of  the  different  articles  enumerated  in  the  treatment  of 
surgical  diseases  will  be  specified  when  they  are  under  consideration. 

The  poisons  that  more  particularly  interest  the  profession  are 
derived  from  these  sources  : 

1st.  From  the  animal  kingdom,  by  which  they  are  produced. 

2d.  From  disease. 

3d.  From  changes  that  occur  after  death. 

Of  the  animal  poisons,  we  will  first  consider  those  secreted  by 
insects  and  serpents,  such  as  the  bee,  wasp,  spider,  and  tarantula, 
as  well  as  some  of  the  varieties  of  the  snake.  I  have  never  known 
any  very  serious  consequence  to  result  either  from  the  sting  of  a 
bee,  wasp,  or  hornet,  or  from  the  bite  of  a  spider.  The  former  are 
followed  by  excessive  pain,  and  sometimes  by  great  sickness  and 
prostration  for  a  few  hours,  and  then  disappear,  even  without 
treatment.  The  bite  of  a  tarantula  is  said  to  be  exceedingly  dangerous. 
They  are  numerous  in  Mexico,  but  fortunately  they  are  met  with 
so  seldom  in  California  that  they  do  not  constitute  a  source  of  ap- 
prehension. In  every  country,  except  that  claimed  by  my  ancestors, 
Old  Ireland,  poisonous  serpents  are  found,  but  the  poison  produced 
by  the  rattlesnake  is  the  most  destructive  to  human  life.  It  is, 
therefore,  exceedingly  important  to  know  how  to  treat  such  cases,  as 
no  time  is  afforded  for  preparation.  The  first  indication  is  to  pre- 
vent the  absorption  of  the  poison  by  placing  a  bandage  above  the 
wound,  or  between  it  and  the  heart,  sufficiently  tight  not  only  to 
check  the  circulation  but  also  to  cut  off  all  communication  between 
it  and  the  heart.  The  wound  should  then  be  enlarged,  so  that  the 
poison  may  be  removed  either  by  suction,  by  the  application  of 
cupping-glasses,  or  by  any  other  small  hollow  vessel  that  may  be 
convenient;  and  then  the  actual  cautery  should  be  applied.  If 
this  course  of  treatment  is  promptly  employed,  the  danger  may  be 
averted.  Should  the  poison  be  absorbed,  in  consequence  of  proper 
assistance  not  being  rendered,  then  you  will  have  both  local  and 
constitutional  symptoms  to  contend  against.  Formerly  aqua  ammo- 
nite, when  used  both  locally  and  generally,  was  considered  a  specific. 
I  am  satisfied  that  when  given  in  teaspoonful  doses,  properly  di- 
luted, and  repeated  every  twenty  or  thirty  minutes,  according  to  the 


252  LECTURES    ON    PRACTICAL    SURGERY. 

urgency  of  the  symptoms,  arid  applied  constantly  to  the  wound,  it 
is  a  remedy  that  deserves  great  confidence. 

Alcoholic  stimulants,  such  as  whisky,  brandy,  and  gin,  when  ad- 
ministered freely,  are  less  unpleasant  to  a  large  majority  of  patients, 
and  equally  efficacious,  very  soon  after  the  bite  has  been  received ; 
if  it  has  not  been  treated  actively  the  part  becomes  painful  and 
swollen,  which  very  soon  involves  the  entire  extremity,  and  some- 
times the  entire  body.  So  soon  as  the  poison  enters  the  circulation 
the  constitutional  depression  becomes  manifest.  The  pulse  is  small, 
the  face  is  pale,  and  the  extremities  are  cold.  The  breathing  soon 
becomes  difficult,  and  death  speedily  follows  if  relief  is  not  afforded. 
I  have  given  a  quart  of  whisky  in  two  hours  without  the  slightest 
symptom  of  intoxication  being  produced.  Give  stimulants  to  sup- 
port the  strength  and  counteract  the  effect  of  the  poison  until  it  is 
eliminated.  If  you  can  prevent  the  patient  from  sinking  for  a  few 
hours,  but  little  danger  should  be  apprehended.  Olive  oil  is  also 
a  powerful  antidote,  and  should  be  given  alternately  with  brandy, 
and  continued  until  rendered  unnecessary  by  the  disappearance  of 
the  constitutional  symptoms.  An  eminent  physician  of  Alabama 
some  years  ago  published  the  result  of  his  experience,  and  it  was 
certainly  very  extensive  and  exceedingly  useful  to  the  inhabitants  of 
the  entire  Southern  country,  in  the  newly  settled  portion  of  which  rat- 
tlesnakes were  so  numerous  that  such  cases  were  of  almost  daily  occur- 
rence. He  advised  every  person  to  keep  themselves  supplied  with 
sweet  oil  and  spirits  of  turpentine.  The  latter  to  be  applied  to  the 
wound  and  the  former  to  be  taken  in  wineglassful  doses  every  ten 
or  fifteen  minutes  until  three  or  four  doses  were  taken,  and  then  the 
quantity  to  be  diminished  and  the  intervals  increased  as  the  violence 
of  the  symptoms  subsided.  When  great  prostration  existed  he  ad- 
vised the  use  of  aqua?  ammonise,  as  already  directed.  He  claimed 
that  this  treatment  was  infallible,  and  there  is  no  doubt  but  it  de- 
served the  high  opinion  entertained  of  its  efficacy  by  Dr.  Hilary 
Herbert,  who  was  the  author  of  the  article  to  which  I  referred. 

The  next  class  of  animal  poisons  is  that  which  results  from  disease, 
as  in  hydrophobia.  In  this  State  physicians  feel  less  interest  in  this 
subject  than  they  do  elsewhere,  because  the  disease  has  not  yet  been 
seen,  and  I  hope  never  will  appear,  on  this  coast.  You  are,  however, 
all  young,  and  may  live  where  hydrophobia  occurs ;  it  therefore 


LECTURE    XXI.  —  HYDROPHOBIA. 

becomes  necessary  that  you  should  be  familiar  with  the  course  of 
treatment  usually  pursued.  I  have  often  travelled  at  night,  when 
making  professional  visits,  with  a  cane  in  one  hand  and  a  revolver  in 
the  other,  and,  on  one  occasion,  even  with  such  weapons,  a  horse- 
rack  saved  me  from  a  large,  powerful  dog,  which  destroyed  a  great 
deal  of  property  before  he  could  be  killed  in  the  morning.  The  bite 
of  a  mad  dog  is  of  course  very  dangerous.  The  disease  which  results 
from  the  wound  is  called  hydrophobia  in  consequence  of  the  constant 
and  dreadful  fear  of  water  exhibited  by  its  victims.  A  rabid  dog 
scarcely  ever  turns  to  the  right  or  left,  but  snaps  at  everything  that 
is  within  his  reach,  which  accounts  for  the  occurrence  of  the  disease 
in  the  human  subject  so  seldom,  considering  the  number  of  dogs 
that  die  from  that  cause  every  year  in  the  Southern  States.  When- 
ever a  wound  is  inflicted  by  a  rabid  animal,  every  portion  of  it  should 
be  removed  with  a  knife  and  the  actual  cautery  applied,  and  then 
dressed  as  if  it  had  resulted  from  any  other  cause.  Medicine  has 
no  control  over  the  disease,  yet  if  I  had  a  patient  suffering  from 
hydrophobia  I  would  keep  him  under  the  influence  of  an  anaesthetic, 
so  as  to  render  him  insensible  and  remove  the  dread  of  the  inevit- 
able consequences  of  such  a  condition.  Mercury,  many  years  ago, 
was  considered  a  specific,  but  subsequent  experience  has  proved  that 
it  does  not  exert  the  slightest  curative  influence.  In  such  cases  nar- 
cotics and  anaesthetics  should  both  be  prescribed,  the  former  enderm- 
ically  and  the  latter  when  the  patient  has  been  secured  in  such  a 
manner  that  resistance  is  impossible.  Hydrophobia  may  be  pre- 
vented by  prompt  and  energetic  treatment,  but  not  cured,  after  the 
symptoms  of  the  disease  have  become  manifest.  You  will  often  be 
consulted  respecting  the  necessity  of  having  a  biting  dog  killed, 
because  it  is  generally  believed  that  if  he  should  at  a  future  time 
become  rabid,  the  person  who  had  been  bitten  would  suffer  from  the 
same  disease.  Nothing  is  more  ridiculous,  although  it  is  universally 
believed.  In  California  you  can  assure  the  public  that  it  is  not 
necessary,  as  hydrophobia  is  unknown  in  that  State.  Before  dismiss- 
ing this  subject,  I  beg  leave  to  recommend  in  all  lacerated  wounds 
produced  by  the  teeth  either  of  men,  dogs,  or  other  animals,  when 
recent,  to  apply  the  remedy  first  used  and  recommended  by  Dr. 
Thomas  Wells,  of  Columbia,  South  Carolina,  which  he  assured  me 
always  prevented  any  unusual  difficulty  in  the  treatment  of  such 
cases,  and  which  I  have,  from  long  experience,  found  to  be  the  only 


254  LECTURES    ON    PRACTICAL    SURGERY. 

application  that  will  deprive  such  wounds  of  any  peculiarity  result- 
ing from  their  cause,  and  places  them  in  a  condition  to  heal  as  readily 
as  those  produced  by  any  other  injury.  If  lint  wet  with  equal  parts 
of  the  ordinary  aqua  ammoniae  and  the  tincture  of  opium  be  applied, 
so  soon  as  they  have  occurred,  twice  a  day,  and  continued  three  or 
four  days,  the  wounds  will  not  inflame,  and  can  then  be  easily  treated 
on  common  principles.  Some  of  the  most  troublesome  cases  I  have 
ever  treated  have  resulted  from  wounds  inflicted  by  the  teeth  both 
of  men  and  the  lower  animals,  and  this  treatment  should  not  be 
forgotten,  because  it  may  save  you  much  trouble  and  relieve  you  of 
great  responsibility. 

The  poison  produced  by  decaying  animal  matter  often  produces  a 
difficulty  of  a  serious  character,  and  one  in  which  you  should  all  feel  in- 
terested. Should  even  a  slight  wound  be  received,  either  in  making 
a  post-mortem  examination  or  in  the  dissecting-room,  particularly  if 
the  general  health  is  not  good,  which  is  often  the  case  with  diligent 
students  near  the  close  of  the  session,  in  a  few  days  the  wound  will 
sometimes  become  painful,  the  lymphatic  vessels  of  the  arm  inflame, 
become  indurated, and  the  diseased  action  may  extend  until  the  consti- 
tutional disturbance  is  sufficiently  great  to  prove  fatal.  Punctured 
wounds  of  this  character  should  be  enlarged,  and  the  nitrate  of  silver 
applied  to  prevent  the  absorption  of  the  poison.  Should  a  red  line  ap- 
pear and  extend  from  the  seat  of  the  injury  towards  the  axilla,  tincture 
of  iodine  should  be  applied  as  soon  as  possible  and  continued  two  or 
three  times  a  day  until  the  part  becomes  insensible  to  its  action.  When 
the  pain  is  violent,  either  opium  or  some  of  its  preparations  should 
be  given,  and  repeated  as  often  as  may  be  necessary  to  afford  relief. 
The  opium  may  be  combined  with  either  calomel,  depressants,  or 
both,  according  to  the  stage  of  the  disease  and  the  condition  of  the 
patient.  So  soon  as  typhoid  symptoms  appear,  give  a  tablespoonful 
of  the  liquor  ammonia  acetatis,  every  three  hours,  with  wine  whey 
and  as  much  simple  nutritious  food  as  the  stomach  can  digest. 

During  the  treatment  of  such  a  case,  the  bowels  should  be  kept 
regular,  either  by  the  occasional  use  of  ten  grains  of  the  extractum 
juglandis  at  night,  or  an  enema,  as  may  be  indicated  by  the 
strength  and  general  condition  of  the  patient.  As  it  is  always  better 
and  often  easier  to  prevent  than  to  cure  a  disease,  I  would  advise 
that  instead  of  wearing  gloves  or  applying  glycerin  to  the  hands 
when  in  the  dissecting-room,  which  interferes  more  or  less  with  the 


LECTURE    XXI.  —  AMPUTATIONS.  255 

use  of  the  knife,  you  should  endeavor  to  acquire  the  power  to  use 
the  knife  dexterously,  and  thus  avoid  a  casualty  of  that  character. 

Amputations. — The  term  amputation  is  sometimes  applied  to  the 
excision  of  the  breast,  although  it  is  generally  confined  to  the  removal 
of  the  extremities.  The  surgeon  is  not  only  interested  in  remov- 
ing the  part,  but  also  in  removing  it  in  such  a  manner  that  what 
remains  will  be  left  in  a  useful  and  healthy  condition.  The  ancients 
were  ignorant  of  the  use  of  the  ligature  in  arresting  haemorrhage, 
which  is  not  surprising,  since  it  was  not  until  the  seventeenth  cen- 
tury that  the  discovery  of  the  circulation  of  the  blood  was  made  by 
Harvey.  The  skin,  muscles,  and  bone  were  then  all  cut  to  the  same 
length,  and  an  effort  made  to  check  the  haemorrhage  by  the  actual 
cautery.  Under  such  treatment  secondary  haemorrhage  must  have 
frequently  occurred.  The  actual  cautery  will  arrest  the  flow  of 
blood  from  a  large  vessel,  but  there  is  always,  under  such  circum- 

FIG.  61. 


stances,  great  danger  of  a  recurrence  so  soon  as  the  slough  is  de- 
tached; hence  we  should  not  rely  upon  anything  but  the  ligature, 
and  that  should  be  applied  sufficiently  tight  to  divide  the  middle 
coat  of  the  artery,  and  then  plastic  lymph  will  be  effused  and  or- 
ganized for  at  least  three-quarters  of  an  inch  above  the  ligature,  which 


256  LECTURES    ON    PRACTICAL    SURGERY. 

will  permanently  obliterate  the  vessel.  In  performing  amputations, 
either  of  two  methods  ma»y  be  employed,  one  known  as  the  circular 
and  the  other  as  the  flap  operation.  The  circular  operation  is  not 
now  in  so  general  use  as  formerly,  yet  in  some  cases  it  should  be 
preferred.  Before  performing  an  operation  of  this  character,  always 
take  the  precaution  necessary  to  prevent  excessive  haemorrhage,  by 
pressure  made  either  with  the  hand  or  a  tourniquet.  The  pioneers 
in  the  profession,  when  they  found  it  necessary  to  check  the  circula- 
tion in  an  extremity,  tied  a  handkerchief,  bandage,  or  some  other 
substance  around  the  limb,  and  then  passed  a  stick  ten  or  twelve 
inches  long  between  the  skin  and  bandage  and  twisted  it  until  the 
circulation  was  arrested.  This  was  called  the  turnstick,  but  has 
since  received  the  name  of  tourniquet.  Sir  Astley  Cooper,  when  a 
boy  twelve  years  old,  arrested  a  haemorrhage  from  the  femoral  artery 
with  his  handkerchief  and  a  stick  until  a  surgeon  could  be  procured 
to  apply  a  ligature.  A  surgeon  and  a  relative  in  London  having 
heard  of  the  circumstance,  sent  for  him,  had  him  educated  in  the 
profession,  and  you  are  familiar  with  the  result.  I  have  mentioned 
this  method  of  arresting  haemorrhage,  as  it  might,  under  certain 
circumstances,  be  found  useful.  You  may  apply  either  the  ordinary 
or  horseshoe  tourniquet,  as  may  be  found  most  suitable  to  the  occa- 
sion. But  you  should  never  forget  that  a  tourniquet  is  always  better 
than  pressure  made  with  the  hand,  because  when  the  muscles  become 
fatigued  the  pressure  diminishes,  and  an  unnecessary  loss  of  blood 
will  be  the  result.  Under  the  pad  of  the  instrument,  which  should 
be  placed  over  the  artery,  a  firm  compress  of  lint  or  cotton  cloth 
should  be  inserted,  and  then  the  pad  should  be  screwed  down  so 
firmly  that  the  pulsation  in  the  artery  ceases  below  the  instrument. 
The  horseshoe  tourniquet  (Fig.  50)  derives  its  name  from  its  shape. 
When  the  patient  is  greatly  exhausted,  and  amputation  becomes  neces- 
sary, I  would  advise  you  to  use  this  instrument,  as  no  pressure  is  made 
upon  the  veins,  and  the  blood  which  they  contain  will  be  returned  to 
the  general  circulation  before  they  are  divided.  I  am  satisfied  that 
the  femoral  at  the  groin  can  be  compressed  so  as  to  control  the  circu- 
lation in  the  artery  more  effectually  than  could  be  done  either  with 
the  thumb,  by  a  key,  or  anything  that  may  be  substituted.  In  my 
lecture  on  aneurism,  particularly  of  the  arteries  of  the  extremities, 
I  gave  directions  for  the  use  of  this  instrument,  which  it  is  unnec- 
essary now  to  repeat. 


LECTURE    XXI.  —  AMPUTATIONS.  257 

Circular  Operation. — After  the  application  of  the  tourniquet  a 
circular  incision  should  be  made  with  an  amputating  knife,  by  which 
the  skin  should  be  divided ;  detach  that  from  the  subjacent  parts 
either  with  the  same  knife  or  a  scalpel,  from  one  to  three  inches 
long,  according  to  the  size  of  the  extremity  to  be  removed,  then 
turn  it  up  and  have  it  retained  by  an  assistant,  and  then  cut  down 
to  the  bone,  dividing  everything  that  intervenes  between  the  integu- 
ment and  that  tissue.  The  skin  and  subjacent  parts  should  then  be 
drawn  upwards,  and  the  bone  divided  as  high  as  possible  with  an 
amputating  saw.  The  vessels  should  then,  even  the  most  minute, 
be  ligated,  and  when  the  haemorrhage  has  been  entirely  arrested, 
the  upper  portion  of  the  wound  should  be  closed  by  the  interrupted 
silver  suture,  a  portion  of  wet  lint  placed  on  the  most  dependent 
part  of  the  wound,  and  the  water-dressing  applied. 

Flap  Operation. — Lowdham,  in  1767,  was  the  first  to  perform  this. 
A  double-edged  knife  is  required  when  this  method  is  adopted ;  pass 
it  perpendicularly  downwards  from  the  centre  of  the  limb  above 
until  the  point  comes  in  contact  with  the  bone,  then  pass  it  around 
and  through  the  limb  to  the  opposite  side,  and  then  cut  downwards 
and  outwards,  making  a  flap  from  two  to  four  inches  in  length. 
The  muscles  always  retract  after  being  divided,  and  as  it  is  im- 
portant to  have  the  bone  well  protected,  it  is  much  better  to  be 
obliged  to  remove  a  portion  of  the  flap  than  either  to  resort  to  force, 
to  prevent  the  protrusion  of  the  bone,  or  to  perform  a  second  opera- 
tion. The  latter  necessity  is  not  unusual,  particularly  in  amputa- 
tions when,  the  patient  is  greatly  emaciated.  This  operation  can 
be  performed  in  less  time  than  the  circular,  and  is  always  preferred 
by  many  surgeons.  I  think  when  it  becomes  necessary  to  amputate 
the  arm  or  thigh  that  it  is  preferable,  but  upon  the  forearm  or  leg, 
particularly  near  the  wrist  or  ankle,  the  circular  should  be  per- 
formed. It  not  only  leaves  a  better  stump,  but  the  wound  will 
also  heal  much  sooner  than  it  would  if  the  flap  was  partly  composed 
of  tendons,  muscles,  and  skin.  An  amputation  may  be  well  per- 
formed, and  if  not  properly  dressed,  and  every  precaution  taken  to 
prevent  a  casualty,  or  should  any  derangement  of  the  general  health 
or  constitutional  peculiarity  exist,  then  one  or  more  of  the  following 
consequences  may  result.  1st.  Haemorrhage ;  2d.  Purulent  absorp- 
tion; 3d.  Extensive  and  unhealthy  suppuration  of  the  stump;  4th. 
Exfoliation  of  bone.  Haemorrhage  may  be  either  primary  or  sec- 

17 


258  LECTURES    ON    PRACTICAL    SURGERY. 

onclary.  When  a  vessel  has  been  cut  and  not  ligated,  although  in 
consequence  of  exposure  it  may  not  bleed,  yet  so  soon  as  the  wound 
is  dressed  and  the  air  excluded,  haemorrhage  may  occur,  which  is 
considered  primary.  When  all  the  vessels  have  been  ligated  and 
haemorrhage  occurs  from  the  sixth  to  the  tenth  day,  it  is  called 
secondary.  A  ligature  may  be  applied  so  near  a  large  branch  that 
the  coagulum  is  not  sufficiently  long  to  protect  the  point  of  adhesion, 
and  secondary  haemorrhage  may  follow,  but  when  a  ligature  has 
been  properly  applied,  and  at  a  point  two  or  three  inches  below  a 
large  branch,  it  is  impossible  for  a  complication  of  that  character  to 
arise.  I  have  never  had  secondary  haemorrhage  to  occur  except 
in  one  case,  and  in  that  the  femoral  artery  was  tied  near  the  groin 
to  arrest  the  flow  of  blood  from  a  wounded  branch  of  the  profunda 
femoris,  which  was  so  profuse  as  to  require  immediate  relief.  On 
the  ninth  day  the  haemorrhage  returned,  and  the  external  iliac 
artery  was  ligated,  and  on  the  third  day  the  patient  bled  to  death 
from  the  vessels  that  were  wounded  in  detaching  the  peritoneum 
from  the  iliac  fossa.  It  would  appear  that  in  that  case  there  existed 
a  haemorrhagic  tendency  which  defied  both  silk  and  surgical  skill. 

I  am  satisfied  that  secondary  haemorrhage  generally  results  from 
the  manner  of  applying  the  ligature.  A  single  knot  should  always 
be  preferred  to  what  is  called  the  surgeon's  knot,  because  the  former 
can  be  drawn  sufficiently  tight  to  divide  the  coats  of  the  vessel, 
which  is  indispensable  to  its  obliteration.  You  are  all  familiar 
with  the  material  used,  as  well  as  the  size  and  method  of  applying 
ligatures.  The  next  difficulty,  and  that  which  is  most  to  be  dreaded, 
is  purulent  absorption,  which  is  almost  always  fatal;  it  may  occur 
in  any  case  where  a  wound  exists.  The  best  way  to  prevent  this 
difficulty  is  to  dress  every  wound  in  such  a  manner  as  to  allow  the 
purulent  secretion  to  escape  readily.  Never  make  an  effort  to  heal 
a  stump  by  the  first  intention.  The  flaps,  for  more  than  two-thirds, 
should  be  approximated  and  retained  in  contact  with  the  interrupted 
silver  suture,  and  in  order  to  secure  proper  drainage,  insert  a  portion 
of  wet  lint  in  the  most  dependent  portion  of  the  wound.  Should 
these  precautions  be  taken,  such  a  difficulty  will  seldom  occur.  I 
shall  always  recollect  with  sorrow  that  after  removing  a  tumor 
from  the  neck  of  a  young  man  in  this  city,  many  years  ago,  I  made 
an  effort  to  heal  it  by  the  first  intention.  His  condition  was  satis- 
factory until  the  fourth  day,  when  he  had  a  chill,  followed  by  a 


LECTURE    XXI.  —  EXFOLIATION    OF    BONE.  259 

violent  fever  and  a  pain  in  the  right  knee.  From  that  time  he  had 
two  paroxysms  of  fever  every  twenty-four  hours,  with  an  increase  of 
pain  in  the  articulations.  On  the  seventh  day  his  breathing  became 
difficult,  and  on  the  ninth  after  the  tumor  was  removed  he  died 
of  purulent  absorption. 

Shortly  afterwards  I  removed  a  fibrous  tumor  from  the  neck  of 
a  woman  about  forty-five  years  old.  The  wound  was  closed  as  usual, 
when  union  by  the  first  intention  is  expected.  On  the  fourth  day 
she  had  a  chill,  followed  by  a  fever  and  a  pain  in  the  left  wrist-joint. 
The  sutures  were  removed  and  the  wound  filled  with  lint  wet  with  ol. 
terebinthinse ;  very  soon  the  symptoms  of  pyaemia  disappeared.  The 
woman  recovered,  and  is  still  living.  The  purulent  matter  that  had 
been  absorbed  was  not  sufficient  to  prove  fatal,  and  her  life  was 
saved  by  the  course  of  treatment  adopted.  Suppuration  of  the 
stump  is  not  of  a  very  serious  character,  because  it  always  occurs  to 
a  greater  or  less  extent,  but  when  the  discharge  is  thin,  bloody,  and 
profuse,  tonics,  with  stimulants,  and  a  generous  diet  should  be  pre- 
scribed. But,  should  the  secretion  be  unhealthy  in  consequence  of 
the  existence  of  inflammation,  cold  applications,  with  the  antiphlo- 
gistic treatment  and  regimen,  should  be  prescribed  and  continued 
until  the  symptoms  are  controlled. 

Exfoliation  of  bone  can  always  be  prevented  by  proper  manage- 
ment. When  the  periosteum  is  injured  exfoliation  must  result. 
You  should,  therefore,  always  use  the  saw  carefully,  so  as  not  to  de- 
tach the  periosteum  above  the  point  at  which  the  bone  is  divided. 
Should  any  spiculse  remain,  or  the  edges  appear  rough  or  abrupt, 
they  should  be  removed  with  the  bone-forceps  to  prevent  the  irrita- 
tion that  must  result  if  they  were  allowed  to  remain. 


260  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   XXII. 

GENTLEMEN  :  We  shall  now  continue  the  consideration  of  am- 
putations. If  we  were  required  to  remove  healthy  limbs,  I  could 
describe  the  operation  required  in  every  case,  but  as  such  operations 
must  be  performed  when  the  part  is  so  much  diseased  as  to  be  no 
longer  useful,  that  method  should  be  adopted  which  will  leave  that 
which  is  preserved  in  a  condition  not  only  to  heal  readily,  but  also 
to  be  useful  and  present  as  little  deformity  as  possible.  The  fingers 
may  be  amputated  either  at  the  joints  or  between  them,  through  the 
phalanges.  The  operation  frequently  becomes  necessary  from  in- 
juries, but  rarely  from  any  other  cause.  The  instruments  needed 
are  all  contained  in  an  ordinary  pocket  case,  except  the  saw,  and 
consist  of  a  scalpel  or  bistoury,  artery  forceps,  a  small  saw  or  bone 
forceps,  and  a  needle,  armed  with  silver  wire,  sufficient  for  three  or 
four  points  of  the  interrupted  suture.  When  it  becomes  necessary 
to  amputate  at  the  first  or  second  joints,  the  finger  should  be  flexed 
as  much  as  possible  without  giving  pain,  and  the  knife  should  be 
drawn  transversely  across  from  right  to  left,  from  an  eighth  to  a 
quarter  of  an  inch  below  the  upper  surface  of  the  finger,  by  which 
both  the  lateral  and  capsular  ligaments  should  be  divided.  The 
knife  should  then  be  passed  behind  the  bone  and  the  flap  formed  on 
the  under  side.  After  the  haemorrhage  has  been  arrested,  the  flap 
should  be  drawn  over  the  articulating  surface,  and  secured  by  one 
or  more  points  of  the  interrupted  suture,  and  the  water-dressing 
applied.  If  it  be  impossible  to  make  the  flap  as  directed,  then  it 
may  be  taken  either  from  one  or  both  sides,  according  to  the  pe- 
culiarity of  the  injury.  Always  amputate  at  the  joint,  if  possible, 
because  there  is  no  danger  of  a  destruction  of  the  cartilage  as  was 
formerly  supposed,  and  more  of  the  fingers  can  be  saved  by  pur- 
suing that  course.  When  the  operation  is  performed  through  the 
phalanges,  a  flap  can  be  formed  on  each  side,  and  when  retracted, 
the  bone  may  be  divided  either  with  a  small  saw  or  bone- forceps,  as 
may  be  most  convenient.  I  generally  prefer  the  latter,  because  it  is 
more  expeditious ;  it  is  entirely  unobjectionable.  It  is  important  in 


LECTURE    XXII.  —  AMPUTATIONS.  261 

every  operation  of  this  character  to  save  as  much  of  the  integument 
as  possible,  and  after  the  bone  has  been  divided,  any  excess  that 
may  exist  can  be  easily  removed  with  the  scissors.  But  little  danger 
should  be  apprehended  from  haemorrhage  after  such  operations. 
When  the  divided  vessels  bleed  freely,  pressure  should  be  made 
upon  the  artery  on  each  side  by  the  finger  and  thumb,  and  the 
haemorrhage  arrested  until  ligatures  can  be  applied.  When  am- 
putation at  the  third  joint  becomes  necessary,  the  flaps  should  be 
lateral.  The  lateral  ligament  being  divided  on  one  side  after  one 
flap  is  made,  the  knife  should  be  passed  through  the  joint,  and  the 
other  formed  as  it  is  withdrawn.  It  should  be  recollected  in  per- 
forming this  operation  that  the  extremity  of  the  bone  is  larger  than 
the  body,  and  consequently,  when  the  knife  meets  with  resistance 
the  edge  should  be  directed  outward  until  the  obstacle  is  passed, 
and  then  turned  directly  inward  to  divide  the  lateral  ligament,  and 
the  operation  completed  as  before  directed.  When  the  metacarpal 
bones  are  diseased,  their  removal  sometimes  becomes  necessary  ;  in 
making  incisions  for  this  purpose  always  be  careful  to  avoid  the 
tendons.  This  precaution  is  very  important,  because  if  the  tendons 
be  divided  the  corresponding  finger  will  be  rendered  useless.  You 
may  remove  the  metacarpal  bones,  and  they  will  be  reproduced  so 
that  the  hand  will  be  as  useful  as  ever,  provided  the  tendons  have 
neither  been  destroyed  by  disease  nor  divided  by  the  knife.  Some 
surgeons  recommend  extensive  incisions  for  the  removal  of  carious 
bones,  but  they  are  entirely  unnecessary.  The  incision  should  be 
only  long  enough  to  expose  the  extremity  of  the  bone,  which  should 
be  elevated  with  a  director  and  removed  with  toothed  forceps. 
Extensive  incisions,  besides  being  unnecessary,  endanger  both  the 
tendons  and  important  bloodvessels,  and  are  neither  more  safe  nor 
more  expeditious.  When  the  hand  has  been  injured,  either  by  gun- 
shot or  other  injuries,  as  I  have  already  advised,  save  as  much  as 
possible,  and  never  amputate  at  the  wrist  unless  the  hand  has  been 
so  much  injured  as  to  render  it  entirely  useless.  You  should  al- 
ways save  as  much  of  an  extremity  as  possible.  Suppose  the  hand 
be  crushed ;  if  sufficient  integument  remains  to  cover  the  bones, 
amputation  should  be  performed  at  the  wrist-joint  rather  than  above 
the  articulation.  A  semilunar  incision  should  be  made  on  both 
sides,  and  when  the  flaps  have  been  raised  the  ligaments  should  be 
divided  and  the  hand  removed.  The  haemorrhage  may  be  arrested 


262  LECTURES    ON    PRACTICAL    SURGERY. 

by  pressure  made  by  a  tourniquet  to  the  arm  until  the  arteries  can 
be  ligated. 

In  amputations  of  the  forearm  I  prefer  the  circular  operation, 
because  it  makes  a  better  stump,  and  the  wound  will  unite  much 
more  readily.  The  first  incision  should  divide  the  skin  and  sub- 
cutaneous cellular  tissue,  which  should  be  drawn  upwards  by  an 
assistant,  and  then  a  second  circular  incision  should  extend  to  the 
bone.  After  the  division  of  the  interosseous  ligament,  the  soft  parts 
should  be  drawn  upwards  and  the  bones  divided  with  a  suitable 
saw,  as  high  as  possible,  for  there  is  nothing  more  awkward  than  to 
find  after  an  operation  that  the  bones  either  protrude  or  can  with 
difficulty  be  concealed  by  the  flaps.  In  performing  such  operations 
always  recollect  that  the  muscles  will  retract,  and  make  proper 
allowance  for  this.  The  next  indication  is  to  check  the  hsemorrhage 
by  ligating  the  vessels,  which  may  be  isolated  either  with  the  te- 
naculum  or  artery  forceps,  because  the  mouth  of  the  vessel  can  be 
closed  by  the  pressure  until  the  ligature  is  applied,  and  the  surgeon 
and  his  assistant  protected.  Generally,  nothing  but  the  artery 
should  be  included  in  the  ligature.  It  is  very  important  to  ligate 
every  vessel  that  bleeds ;  and  never  dress  the  wound  until  the 
hemorrhage  has  entirely  ceased.  It  is  better  to  wait  an  hour  than 
to  be  compelled  to  remove  the  dressings.  In  consequence  of  pur- 
suing this  course,  I  have  not  for  the  last  twenty  years  been  com- 
pelled to  remove  the  dressings  in  order  to  ligate  a  bleeding  vessel. 

The  success  of  the  operation  depends  more  upon  the  manner  in 
which  the  stump  is  dressed  than  upon  everything  else  combined. 
The  ligatures,  if  numerous,  should  be  placed  in  the  most  dependent 
position  of  the  wound,  and  if  not,  a  strip  of  wet  lint  should  oc- 
cupy that  position  for  the  purpose  of  preventing  the  union  of  that 
part  of  the  wound  by  the  first  intention.  After  approximating  the 
edges  of  the  superior  portion  of  the  wound  by  the  interrupted  silver 
suture,  the  water  dressing  should  be  put  on,  and  retained  by  a 
roller  bandage  very  loosely  applied.  Many  lives  have  been  sacri- 
ficed by  endeavoring  to  heal  the  wound  by  the  first  intention. 
When  the  edges  of  the  entire  wound  are  approximated,  arid  dry  lint 
is  applied  and  secured  by  a  tight  bandage,  the  purulent  secretion 
cannot  escape ;  often  in  four  or  five  days  the  symptoms  of  pyaemia 
appear  and  increase  until  the  function  of  some  important  organ  is 
so  much  disturbed  as  to  destroy  life.  Almost  all  young  surgeons 


LECTURE    XXII.  —  AMPUTATIONS.  263 

apply  bandages  too  tightly.  After  every  operation  and  injury,  the 
parts  implicated  must  swell,  for  which  proper  allowance  should  al- 
ways be  made.  After  dressing  the  wound  as  directed,  if  no  idio- 
syncrasy exists,  give  sulphate  of  morphia  in  sufficient  doses  to 
relieve  the  pain,  and  repeat  it  as  often  as  necessary  during  the  three 
or  four  succeeding  days  for  the  purpose  of  preventing  inflammation. 
I  have  told  you  this  perhaps  more  than  once  before,  but  whatever  is 
so  important  to  success  will  bear  to  be,  and  should  be,  repeated. 

Upon  the  forearm,  but  near  the  elbow-joint,  the  flap  operation 
may  be  performed.  A  double-edged  knife  should  be  passed  into 
the  external  side  of  the  arm  until  the  point  comes  in  contact  with 
the  radius ;  the  blade  should  then  be  passed  in  front  of  that  bone 
until  it  appears  upon  the  ulnar  side,  and  then  by  a  sweep  down- 
wards and  outwards  the  anterior  flap,  about  three  inches  long,  should 
be  made.  The  knife  should  then  be  inserted  at  the  same  point 
and  passed  posterior  to  the  bones,  and  a  flap  made  similar  to  the 
first.  These  flaps  should  then  be  drawn  upwards  by  an  assistant,  and 
the  bones  divided  by  a  suitable  saw.  Formerly,  the  joints  were 
carefully  avoided,  but  sometimes  you  can  amputate  at  the  elbow- 
joint  with  great  advantage.  I  saw  Dupuytren  perform  this  opera- 
tion in  the  Hotel  Dieu.  After  making  an  anterior  flap,  the  head  of 
the  radius  was  detached  and  the  ulna  was  divided  with  a  saw, 
leaving  the  olecranon  process  and  the  attachment  of  the  extensor 
muscles  undisturbed.  It  was  much  less  difficult  to  divide  the  ulna 
with  a  saw  than  it  would  have  been  to  separate  it  from  its  attach- 
ments, as  well  as  much  more  expeditious  and  less  dangerous. 

When  it  becomes  necessary  to  amputate  the  arm,  I  prefer  the  cir- 
cular operation.  I  cannot  boast  of  the  number  of  operations  of 
this  character  which  I  have  performed,  but  I  can  say  that  I  have 
never  lost  a  patient  after  any  operation  upon  the  superior  extremity. 
Always  practice  conservative  surgery,  because  it  requires  more  skill, 
and  it  is  more  creditable  to  save  than  to  destroy  an  important  mem- 
ber of  the  body.  I  prefer  the  circular  operation,  because  you  can  make 
a  better  stump.  The  wound  can  be  more  effectually  drained,  and 
the  danger  of  pysemia  greatly  diminished.  Always  save  as  much 
of  the  arm  as  possible ;  but  in  the  effort  to  do  this,  you  should  not 
fail  to  leave  a  sufficient  covering  for  the  bone.  Amputation  at  the 
shoulder-joint  may  become  necessary  when  the  humerus  is  exten- 
sively diseased,  or  when  it  is  severely  injured,  either  by  gunshot  or 


264  LECTURES    ON    PRACTICAL    SURGERY. 

other  wound.  You  should  in  such,  as  in  all  other  cases,  be  governed 
by  circumstances,  hence  the  operation  selected  must  depend  on  the 
character  of  the  injury.  It  is  sometimes  most  convenient  to  make 
a  flap  of  the  deltoid  muscle  by  passing  the  knife  transversely 
between  the  acromion  process  of  the  scapula  and  the  head  of  the 
burner  us,  by  which  the  capsular  ligament  will  be  opened  so  as  to 
avoid  the  deltoid  muscle,  which  should  then  be  divided  by  a  sweep 
of  the  knife  directed  downward  and  outward.  The  flap  should  now 
be  turned  upward  to  expose  the  joint.  The  head  of  the  humerus 
should  be  dislocated,  and  as  soon  as  the  artery  can  be  compressed  by 
a  competent  assistant,  the  lower  or  inferior  flap  should  be  made  and 
the  extremity  removed.  A  good  assistant  is  very  important  when 
this  operation  is  performed,  as  the  hemorrhage  can  be  controlled 
much  more  easily  by  compressing  the  axillary  than  the  subclavian 
artery.  The  first  time  I  performed  this  operation  in  California 
was  upon  a  man  in  the  County  Hospital,  who  had  caries  of  the  entire 
humerus,  as  well  as  of  about  three  inches  of  the  superior  extremities 
of  both  the  radius  and  ulna.  So  soon  as  the  articulating  extremity 
of  the  humerus  was  dislodged,  Dr.  R.  McMillan,  of  this  city,  arrested 
the  circulation  in  the  artery  by  passing  his  fingers  behind  the  bone 
and  making  pressure  above  the  point  at  which  the  artery  was  di- 
vided in  making  the  flap.  You  may  find  it  necessary,  in  conse- 
quence of  the  condition  of  the  soft  parts,  to  make  an  anterior  and 
posterior  flap,  which  is  not  more  difficult  than  the  operation  de- 
scribed. The  knife  should  be  entered  on  the  outer  side  of  the 
humerus  perpendicularly  from  above  downwards,  so  as  to  make 
the  external  flap,  which  should  be  at  least  four  inches  in  length. 
The  capsular  ligament  should  then  be  divided,  and  the  head  of  the 
bone  thrown  outwards.  Before  completing  the  operation,  the  artery 
should  be  controlled  by  an  assistant,  as  before  directed,  and  an  in- 
ternal flap  made  to  correspond  both  in  width  and  length  with  the 
external.  The  wound  resulting  from  an  amputation  at  the  shoulder- 
joint  should  be  dressed  in  the  usual  way,  great  care  being  taken  to 
secure  the  escape  of  the  secretions,  on  account  of  the  great  extent  of 
the  wound. 

When  it  becomes  necessary  to  remove  the  toes,  the  same  course 
should  be  pursued  which  was  recommended  in  amputation  of  the 
fingers.  Erichsen  recommends  a  tourniquet  to  be  applied  to  the 
femoral  artery,  provided  the  patient  be  greatly  debilitated,  which,  I 


LECTURE    XXII.  —  AMPUTATIONS.  265 

think,  is  entirely  unnecessary,  as  the  haemorrhage,  if  profuse,  can 
be  controlled  by  pressure  made  upon  the  anterior  and  posterior  tibial 
arteries.  The  toes  may  be  removed  either  at  the  joints  or  through 
the  bones,  between  the  articulations,  but  when  either  the  great  or 
little  toes  are  amputated,  it  will  contribute  greatly  to  the  comfort  of 
the  patient  to  remove  at  the  same  time  a  portion  of  the  extremity 
of  the  metatarsal  bone.  If  allowed  to  remain,  this  would  prove  a 
source  of  constant  annoyance,  as  the  patient  would  find  it  impossi- 
ble to  wear  an  ordinary  shoe  without  great  inconvenience.  It  should 
be  done  obliquely,  either  with  a  small  saw  or  bone-forceps,  which  I 
prefer,  and  with  the  variety  exhibited,  they  can  be  removed  wher- 
ever it  may  be  necessary.  When  a  metatarsal  bone  is  only  partially 
diseased,  the  carious  portion  should  be  exposed  and  detached  either 
with  the  bone-forceps  or  chisel,  according  to  the  locality  and  extent  of 
the  disease.  When  the  integuments  as  well  as  the  metatarsal  bones 
are  so  much  diseased  that  the  removal  of  the  latter  would  not  effect 
a  cure,  there  are  two  operations  that  may  be  performed,  either  of 
which  is  better  than  amputation  above  the  ankle-joint.  In  the  first, 
which  is  called  Chopart's,  both  the  astragalus  and  os  calcis  are  saved. 
Formerly  the  os  cuboides  was  not  disturbed,  but  it  is  now  considered 
better  to  remove  it  before  the  wound  is  dressed.  In  this  operation 
the  first  incision  should  be  semilunar  and  extend  from  the  projection 
made  by  the  articulation  of  the  metatarsal  bone  of  the  little  toe  to  a 
corresponding  point  on  the  opposite  side.  When  the  flap  has  been 
dissected  up,  the  toes  should  be  pressed  downwards  and  the  knife 
drawn  directly  across  the  foot  so  as  to  pass  through  in  front  of  the 
astragalus,  cuboid,  and  os  calcis.  The  lower  flap  can  be  formed  from 
the  sole  of  the  foot ;  should  that,  however,  be  destroyed  by  disease^ 
and  the  integument  on  the  upper  portion  be  healthy,  a  sufficient 
quantity  should  be  preserved  to  cover  in  the  wound,  after  the  cuboid 
has  been  removed.  Some  surgeons  dissect  up  the  inferior  flap  be- 
fore the  superior  incision  is  made,  which,  I  think,  is  objectionable, 
because  it  renders  the  operation  more  tedious  and  less  elegant,  it 
being  impossible  to  determine  accurately  the  precise  point  at  which 
the  disarticulation  can  be  effected.  When  it  becomes  necessary  to 
operate  above  the  point  recommended  by  Chopart,  PirogofF's  opera- 
tion, which  is  a  modification  of  Syme's,  should  be  performed.  The 
first  incision  should  be  semilunar,  and  extend  from  the  internal  to 
the  external  malleolus.  When  the  flap  has  been  dissected  up  the  lat- 


266  LECTURES    ON    PRACTICAL    SURGERY. 

eral  ligaments  of  the  ankle-joint  should  be  severed,  the  astragalus 
removed,  and  then  a  transverse  incision  should  be  made  across  the 
sole  of  the  foot  in  front  of  the  os  calcis,  and  then  that  bone  should 
be  divided  longitudinally  through  the  centre  with  an  amputating 
saw ;  the  articulating  surfaces  of  the  tibia  and  fibula  should  be  re- 
moved, and  the  portion  of  the  os  calcis  which  remains  should  be 
brought  up  and  retained  in  contact  with  the  extremities  of  the  bones 
of  the  leg  by  the  interrupted  silver  suture.  When  this  operation  is 
performed,  union  takes  place  between  the  os  calcis  and  the  tibia  as  in 
an  ordinary  fracture,  and  the  stump  is  superior  to  that  which  results 
either  from  Ch  opart's  or  Syme's  operations.  You  have  seen  this 
operation  performed  twice  in  the  hospital,  and  I  was  entirely  satisfied 
with  the  result.  When  PirogofPs  operation  is  performed,  the  an- 
terior portion  of  the  bones  of  the  leg  should  be  left  longer  than  the 
posterior,  as  a  better  and  more  useful  stump  will  result.  Syrne  per- 
formed the  operation  as  described,  except  that  instead  of  dividing  the 
os  calcis  it  was  removed,  and  the  stump  was  covered  only  by  the  ordi- 
nary integument  of  the  heel.  I  have  performed  every  operation  that 
has  been  recommended  upon  the  foot,  and  I  prefer  PirogofFs,  whether 
the  modification  I  have  recommended  be  adopted  or  not,  to  either 
Chopart's  or  Syme's.  The  extremity  is  longer  than  in  Syme's,  and 
more  useful  than  in  Chopart's,  in  consequence  of  the  elevation  of  the 
heel  in  the  latter,  which  is  unavoidable,  unless  the  tendo  Achillis  is 
divided,  and  the  subsequent  treatment  properly  conducted.  In  all 
operations,  either  upon  the  foot  or  leg,  the  tourniquet  should  always 
be  applied  to  prevent  excessive  haemorrhage,  and  as  much  of  the 
limb  should  be  saved  as  possible.  When  it  becomes  necessary  to 
amputate  above  the  ankle,  the  circular  operation  should  always  be 
preferred.  Near  the  knee-joint  a  flap  can  be  taken  from  the  pos- 
terior part  of  the  leg  long  enough  to  cover  the  bones  and  leave  a  good 
stump.  Formerly  when  the  foot  or  ankle  were  diseased,  the  leg  was 
always  removed  as  near  the  knee-joint  as  possible,  because  the  ordi- 
nary wooden  leg  was  used  with  the  knee  resting  upon  a  pad,  and 
by  operating  as  near  the  knee  as  possible  the  annoyance  and  incon- 
venience resulting  from  the  posterior  projection  of  the  stump  was  re- 
moved. Palmer's  artificial  leg  is  composed  of  cylinders  and  joints, 
the  former  being  made  to  correspond  with  the  size  of  the  stump, 
and  so  arranged  that  the  pressure  is  equally  distributed.  If  the  dis- 
ease of  the  leg  be  so  near  the  knee  that  the  operation  cannot  be 


LECTURE    XXII. —  AMPUTATIONS.  267 

performed  below  the  joint,  and  the  articulating  surfaces  are  not  im- 
plicated, you  can  then  either  operate  through  the  joint  or  a  few 
inches  above.  The  former  will  leave  a  better  stump,  particularly 
when  the  patella  can  be  saved,  as  the  attachment  of  the  extensor 
muscles  will  not  be  disturbed.  After  the  anterior  flap  has  been 
raised,  the  knife  should  be  passed  behind  the  bones  and  a  flap  from 
five  to  six  inches  formed  from  the  gastrocnemii  muscles.  It  is  very 
important  to  provide  a  sufficient  covering,  and  if  in  excess,  it  can 
easily  be  removed.  Prof.  Gross  thinks  that  the  articulating  surface 
should  not  be  disturbed,  and  Dr.  Thomas  Wells,  of  Columbia,  South 
Carolina,  amputated  at  the  knee-joint  successfully  as  early  as  1833. 
Should  the  articulating  surface  be  diseased,  then  the  bone  should  be 
removed  as  near  the  joint  as  possible,  there  being  less  danger  of 
osteitis  resulting  from  passing  the  saw  through  the  spongy  than  the 
solid  portion  of  the  bone. 

Amputation  at  the  knee-joint  was  performed  by  Hildanus  in  1581, 
Velpeau  revived  it  in  1830,  and  Dr.  Thomas  Wells,  as  before  men- 
tioned, operated  in  1833.  Since  that  time  it  has  been  practiced  by 
the  best  surgeons  in  the  United  States  in  suitable  cases. 

When  the  thigh  must  be  removed  above,  but  near  the  knee,  you 
should  make  the  anterior  flap  from  the  integument  covering  the 
joint,  and  the  posterior  as  already  described,  and  save  as  much  of 
the  femur  as  possible,  for  even  one  inch  is  of  great  importance  to  the 
patient.  A  few  inches  higher  up  an  amputating  knife  may  be 
passed  perpendicularly  as  may  be  thought  advisable,  and  a  flap 
formed  by  a  single  sweep  of  the  knife,  and  the  second  in  the  same 
manner.  When  these  are  retracted  the  bone  should  be  divided,  the 
arteries  secured,  and  the  wound  dressed  as  already  described. 

Amputation  at  the  hip-joint  is  always  a  very  grave  operation,  and 
has  frequently  proved  fatal.  You  should  therefore  feel  that  it  is  in- 
dispensable, and  that  it  is  recommended  as  a  last  alternative.  In  one 
of  the  operations  which  I  performed  at  the  hip-joint,  the  patient's 
life  was  endangered  from  haemorrhage  in  consequence  of  the  assist- 
ant having  failed  to  control  the  circulation  of  the  femoral  artery. 
When  that  vessel  was  divided  the  blood  flew  across  the  room  in  a 
stream  as  large  as  the  vessel,  until  it  was  seized  with  the  forefinger 
and  thumb  of  the  left  hand  and  held  until  a  ligature  was  applied. 
In  such  cases  never  rely  upon  an  assistant,  but  apply  Prof.  Gross's 
tourniquet  either  below  or  above  Poupart's  ligament,  and  then  you 


268  LECTURES    ON    PRACTICAL    SURGERY. 

will  feel  that  your  patient  is  not  in  danger  of  losing  his  life  from 
that  cause. 

The  operation  may  be  performed  by  passing  the  knife  from  a 
point  two  inches  below  the  anterior  superior  spinous  process  of  the 
ilium,  obliquely  downwards,  so  as  to  endanger  neither  the  other 
thigh,  the  scrotum,  nor  the  urethra.  The  knife  should  be  passed  as 
near  the  bone  as  possible,  and  the  flap  should  be  four  or  five  inches  in 
length.  The  capsular  ligament  should  then  be  divided  and  the  head 
of  the  bone  dislocated  ;  the  posterior  flap  should  be  cut  corresponding 
with  the  anterior.  Should  an  external  and  internal  flap  be  preferred, 
the  external  should  be  first  made,  and  after  the  head  of  the  bone  is 
dislocated  an  assistant  should  hold  the  soft  parts  in  such  a  manner 
as  to  make  sufficient  pressure  upon  the  artery  to  prevent  all  risk  of 
haemorrhage.  After  ligating  the  vessels  the  wound  should  be 
closed  by  the  interrupted  silver  suture,  the  water  dressing  applied, 
and  half  a  grain  of  the  sulph.  morphine  administered  to  relieve 
pain.  Should  reaction  not  occur  speedily,  stimulants  should  be  ad- 
ministered as  indicated  by  the  condition  of  the  patient. 


LECTURE   XXIII. — FRACTURES.  269 


LECTUKE  XXIII. 

GENTLEMEN  :  As  announced,  I  will  to-day  lecture  on  fractures, 
an  exceedingly  important  subject  to  every  practitioner  of  medicine. 
Almost  all  the  suits  for  malpractice  are  based  upon  the  alleged  im- 
proper treatment  of  fractures,  and  sometimes  of  the  most  simple 
variety.  It  is  necessary,  therefore,  that  you  should  understand  them 
perfectly. 

Bones  differ  from,  and  are  distinguished  from,  all  other  portions  of 
the  body  by  their  great  power  of  reproduction.  When  a  bone  is 
broken  a  sufficient  quantity  of  new  bone  is  formed  to  unite  the  ex- 
tremities, which  does  not  occur  in  any  other  tissue  of  the  body.  For 
instance,  if  a  muscle  be  divided,  it  will  not  unite  except  by  the  inter- 
vention of  fibrous  tissue,  but  even  when  a  bone  is  shattered,  union 
will  take  place,  provided  the  soft  parts  are  not  too  seriously  injured. 
Even  when  a  bone  loses  its  vitality,  it  may  be  removed,  and  should 
the  periosteum  remain,  new  bone  will  be  reproduced.  When  I  pub- 
lished, a  few  years  since,  in  the  Pacific  Medical  Journal,  that  bones, 
joints,  and  ligaments  could  be  reproduced,  the  daily  papers  were 
filled  with  abusive  articles,  written  by  members  of  the  profession  in 
this  city,  in  which  they  at  first  contended  that  it  was  impossible 
and  that  my  statements  were  not  true.  But  when  the  name  and 
address  of  every  party  who  had  been  operated  upon  was  given,  and 
the  result  proved  that  not  only  the  bones  and  joints  of  entire  fingers 
can  be  reproduced,  but  also  the  bones  of  the  foot  and  ankle,  the 
inferior  maxillary,  as  well  as  the  bones  of  the  forearm,  with  the 
articulating  surfaces,  they  protested  that  everything  claimed  was  and 
had  been  known  to  the  profession  for  more  than  forty  years,  and 
hence  that  no  discovery  had  been  made. 

A  fracture  is  a  solution  of  continuity  in  a  bone,  produced  by  vio- 
lence, which  may  act  directly  upon  the  part  injured.  Suppose  a 
heavy  weight  were  to  fall  upon  rny  arm,  the  bone  would  be  broken 
directly  at  the  point  where  the  force  was  applied,  or  it  may  result 
from  the  force  being  applied  to  a  distant  part.  If  a  person  were  to 
fall  upon  the  feet,  from  an  elevation  of  five  or  six  yards,  it  is  highly 


270          LECTURES  ON  PRACTICAL  SURGERY. 

probable  that  one  or  both  thighs  would  be  fractured.  I  am  now 
treating  a  patient  who  has  a  fracture  of  both  legs,  produced  by  jump- 
ing from  the  driver's  seat  of  a  stage-coach  when  it  was  in  rapid 
motion.  The  force  was  applied  to  the  feet,  and  the  legs  were  frac- 
tured several  inches  above  the  ankles.  A  fracture  may  result  from 
inordinate  muscular  action.  I  treated  a  case,  many  years  ago,  of 
fracture  of  the  thigh-bone  near  the  centre,  sustained  by  a  young 
powerful  man  in  running  a  foot  race.  The  patella  is  also  sometimes 
fractured  by  the  action  of  the  extensor  muscles  of  the  thigh.  I  have 
treated  two  cases  of  that  character,  which  resulted  from  carriage 
drivers  being  dragged  from  the  seat ;  in  consequence  of  the  great 
muscular  effort  made  to  save  themselves  the  patella  was  fractured 
transversely  in  both  cases.  Fractures  occur,  however,  more  fre- 
quently from  direct  violence,  or  from  force  being  applied  to  a  distant 
part,  than  from  muscular  contraction. 

Fractures  occur  at  all  ages,  but  the  bone  is  not  always  broken  at 
the  same  point  from  a  similar  cause.  When  the  thigh  of  a  child  is 
fractured,  it  is  generally  about  the  middle,  but  when  an  old  man 
sustains  an  injury  of  that  character,  it  occurs  almost  always  at  the 
neck  of  the  bone.  You  should  not  forget  this  fact,  as  it  might  lead 
to  as  great  a  mistake  as  was  committed  by  Lisfranc,  at  the  La  Pitie 
Hospital,  in  Paris.  He  announced  to  the  class  that  an  old  man  in 
the  ward  had  a  dislocation  of  the  hip-joint,  which  would  be  reduced 
the  following  day.  Some  of  the  students  formed  a  different  opinion 
of  the  character  of  the  injury.  On  the  day  appointed  an  immense 
crowd  of  students  assembled,  both  to  see  a  case  of  dislocation  of  the 
hip-joint,  which  rarely  occurs,  as  well  as  to  witness  the  reduction  by 
so  distinguished  a  surgeon.  When  extension  was  made  by  three  or 
four  assistants,  the  limb  was  readily  placed  in  its  proper  position,  but 
so  soon  as  the  extending  power  was  removed  it  presented  its  former 
appearance.  The  students  were  soon  convinced  that  an  error  had 
been  made  in  the  diagnosis,  and  their  remarks  were  anything  but 
complimentary  to  the  surgeon.  I  treated  a  case  of  this  character, 
which  occurred  to  an  old  physician  (he  was  in  his  one  hundred  and 
twelfth  year),  that  was  mistaken  for  a  dislocation  of  the  hip-joint. 
He  suffered  greatly  from  the  effort  made  by  his  former  attendant  to 
effect  the  reduction.  Always  be  careful  in  expressing  an  opinion, 
particularly  if  the  patient  has  passed  the  age  of  sixty,  because  the 
bones  generally  by  that  time  become  brittle,  and  are  more  liable  to 


LECTURE    XXIII.  —  FRACTURES.  271 

break  than  to  be  dislocated.  I  have  treated  many  cases  of  fracture 
of  the  neck  of  the  femur  in  old  people,  but  never  a  dislocation  of 
the  hip-joint. 

Fractures  may  be  either  transverse  or  oblique.  If  a  bone  be 
broken  directly  across  the  shaft  it  is  called  a  transverse  fracture,  and 
if  obliquely  in  respect  to  the  axis,  it  is  called  an  oblique  fracture, 
which  is  much  the  most  difficult  to  treat,  because  the  displacement  is 
greater  and  it  is  more  difficult  to  retain  the  broken  ends  in  apposi- 
tion. In  a  transverse  fracture,  when  the  extremities  of  the  bones  are 
placed  in  contact,  they  can  be  easily  retained  in  that  position  by  the 
application  of  moderate  pressure,  and  in  such  cases  there  will  be  but 
little,  if  any,  shortening  of  the  limb.  In  oblique  fractures  of  the 
thigh  it  requires  great  care  to  prevent  a  diminution  in  the  length, 
and  some  surgeons  contend  that  from  half  to  three-quarters  of  an 
inch  is  inevitable.  I  am  satisfied  that  it  is  not  so,  and  many  of  you 
saw  a  case  treated  in  the  County  Hospital  in  which  no  difference 
could  be  detected  in  the  length  of  the  extremities. 

A  fracture  is  said  to  be  simple,  when  the  bone  is  broken  and  the 
soft  parts  have  sustained  no  injury.  This  cut  (Fig.  62)  represents  a 


simple  transverse  fracture  of  the  neck,  with  the  head  of  the  bone  in 
the  acetabulum.    The  following  cut  (Fig.  63),  will  give  you  a  correct 


272          LECTURES  ON  PRACTICAL  SURGERY. 

idea  of  the  appearance  of  a  bone  broken  in  several  pieces,  or  in  other 
words  shattered.  This  is  called  a  comminuted  fracture.  The  words 
single  and  comminuted,  simple  and  compound,  include  every  variety, 
as  both  transverse  and  oblique  fractures  may  be  either  single  or  com- 
minuted. A  single  and  simple  fracture  is  said  to  exist  when  the 


FIG.  63. 


bone  is  broken  only  at  one  point,  and  no  external  wound  exists,  but 
when  a  bone  is  crushed,  either  with  or  without  an  external  wound, 
the  fracture  is  called  comminuted.  Whenever  a  solution  of  conti- 
nuity in  a  bone  is  complicated  with  an  external  wound  communica- 
ting with  it,  you  have  a  case  of  compound  fracture.  Should  the 
same  injury  to  the  bones  exist,  without  the  external  wound,  it  would 
be  called  simple.  To  repeat,  when  a  fracture  extends  straight  across 
the  body  of  a  bone  it  is  transverse,  oblique  when  the  opposite  sides 
are  broken  at  different  points,  single  when  there  is  a  simple  solution 
of  continuity,  comminuted  when  the  bone  is  broken  into  several 
pieces^  and  compound  when  complicated  with  an  external  wound. 

Symptoms. — Distortion  of  the  limb  is  rarely  absent.  Even  when 
the  displacement  of  the  extremities  is  slight,  the  appearance  of  the 
part  differs  from  that  which  it  ordinarily  presents.  If  the  thigh- 
bone be  fractured  obliquely,  the  distortion  and  shortening  of  the 
extremity  will  be  great  in  proportion  to  the  direction,  the  violence, 
and  nature  of  the  cause.  In  such  cases,  when  improperly  treated, 
the  thigh  is  frequently  shortened  three  or  four  inches,  and  the  patient 
rendered  a  cripple.  From  three-fourths  of  an  inch  to  an  inch  is 


LECTURE    XXIII.  —  FRACTURES.  273 

excusable,  and  has  been  so  characterized  by  the  best  authorities  on 
surgery. 

There  is  a  total  loss  of  power  when  the  thigh  or  arm  is  fractured, 
but  if  only  one  bone  of  the  leg  or  forearm  is  broken,  there  is  a  dimi- 
nution but  not  a  total  loss;  there  is  also  preternatural  mobility. 
The  limb  can  be  easily  moved  in  any  direction  without  the  applica- 
tion of  much  force,  which  was  the  reason  that  some  of  the  students 
had  arrived  at  the  conclusion  that  the  patient  in  the  La  Pitie"  Hos- 
pital, whom  I  have  already  mentioned,  had  a  fracture  of  the  neck 
of  the  thigh-bone  instead  of  a  dislocation  of  the  hip-joint.  There 
is  always  more  or  less  swelling  from  effusion,  and  for  that  reason, 
whenever  you  are  called  to  a  case  of  fracture,  it  should  be  reduced 
before  that  occurs.  It  depends  both  upon  the  extravasation  of  blood 
and  the  effusion  of  serum,  and  results  from  the  increased  action  of 
the  vessels  produced  by  the  irritation  inseparable  from  such  an  in- 
jury- 

The  patient  always  suffers  from  pain,  and  often  from  a  spasmodic 

twitching  of  the  muscles,  which  exists  in  a  greater  or  less  degree 
according  to  the  locality  of  the  injury.  In  fractures  of  the  arm, 
particularly  if  accompanied  by  much  laceration  of  the  muscles,  this 
symptom  is  exceedingly  troublesome  and  distressing.  It  also  fre- 
quently occurs  in  fractures  both  of  the  leg  and  thigh,  and  in  the 
latter  it  is  generally  very  annoying  at  night,  unless  prevented  by  the 
administration  of  some  preparation  of  opium.  The  most  important 
symptom  of  fracture  is  crepitation.  This  is  always  present.  It  can 
generally  be  both  felt  and  heard,  and  when  you  have  once  experi- 
enced the  sensation  imparted  to  the  fingers  by  rubbing  the  jagged 
ends  of  the  bone  together  you  can  never  mistake  it  for  anything 
else.  There  is  nothing  which  resembles  it,  except  it  be  the  crackling 
produced  by  the  contraction  of  an  injured  muscle,  and  then  all  the 
other  symptoms  of  fracture  are  absent.  This  only  occurs  when  the 
sheath  of  a  tendon  has  been  injured  in  consequence  of  the  absence  of 
the  lubricating  fluid,  the  secretion  of  which  is  arrested  by  the  inflam- 
mation produced  by  the  injury. 

When  a  fracture  exists,  by  what  agency  is  the  bone  united  ? 
This  was  formerly  a  controverted  point,  many  contending  that  the 
periosteum  did  not  perform  that  office,  and  even  within  the  last  few 
years  an  eminent  surgeon  of  this  city  published  an  article  in  the 
first  number  of  the  Pacific  Medical  Journal,  in  which  he  not  only 

18 


274  LECTURES    ON    PRACTICAL    SURGERY. 

asserted  but  endeavored  to  prove  that  the  periosteum  did  not  con- 
tribute in  the  slightest  degree,  either  to  the  reproduction  or  reunion 
of  bone,  which  opinion  is  not  now  sustained  by  any  respectable 
surgeon.  Without  the  periosteum,  a  bone  can  neither  live,  be  re- 
stored when  removed,  nor  be  united  when  fractured.  Whenever  a 
bone  is  deprived  of  its  periosteum  the  part  exposed  always  loses  its 
vitality.  The  best  proof  I  have  ever  had  of  the  truth  of  this  assertion 
was  presented  by  a  case  of  cancer  of  the  scalp,  which  I  treated  in 
the  St.  Mary's  Hospital  of  this  city.  After  the  tumor  was  removed, 
believing  it  to  be  malignant,  in  order  to  prevent  a  recurrence  the 
periosteum  was  detached  from  the  entire  surface  of  the  cranium,  to 
which  the  tumor  was  attached.  In  three  or  four  months  the  ex- 
ternal table  of  the  bone  exfoliated.  The  most  unpleasant  recol- 
lection connected  with  that  case  is  that  the  operation  did  not  afford 
permanent  relief.  After  being  apparently  well  for  a  few  months, 
the  internal  table  of  the  bone  became  diseased,  which  being  de- 
stroyed, the  brain  soon  became  implicated  and  a  fatal  result  ensued. 
A  fracture  should  be  reduced  as  soon  after  the  receipt  of  the 
injury  as  possible,  and  before  the  surrounding  parts  become  suffi- 
ciently swollen  to  conceal  the  true  character  of  the  injury ;  it 
should  then  be  placed  in  the  position  least  inconvenient  to  the 
patient.  A  fractured  bone,  after  the  first  six  or  eight  hours,  is  not 
necessarily  painful,  but  such  patients  usually  suffer  greatly  from 
the  dressings.  Avoid  tight  bandages  always,  and  more  particularly 
at  first.  If  sufficient  allowance  is  not  made  for  the  swelling  that 
must  follow  such  an  injury,  the  patient  will  suffer  so  much  pain 
that  even  the  free  use  of  opium  will  not  insure  him  sleep;  the  loss 
of  which  will  produce  so  much  constitutional  disturbance,  that  the 
object  of  the  treatment  will  be  defeated.  Always  apply  the  bandages 
for  seven  or  eight  days,  tight  enough  only  to  keep  the  extremities 
of  the  bone  from  irritating  the  surrounding  parts,  and  then  you 
should  ascertain  the  condition  of  the  limb  and  the  position  of  the 
fracture.  By  that  time,  if  the  proper  treatment  has  been  pursued, 
the  swelling  will  have  disappeared  sufficiently  to  enable  you  to 
judge  whether  a  change  is  necessary  or  not,  and  then  it  should  be 
dressed  as  you  intend  it  to  remain,  because  now  the  deposition  of 
coagulable  lymph  commences,  and  very  soon  the  ends  of  the  bone 
will  be  united  ;  if  they  have  not  been  properly  adjusted, .it  not  only 
becomes  difficult  to  change  the  position,  but  also  exposes  the  patient 


LECTURE    XXIII.  —  FRACTURES.  275 

to  the  danger  of  a  false  joint.  I  repeat,  in  seven  days  sufficient 
action  is  established  in  the  periosteum  in  the  vicinity  of  the  fracture 
to  surround  the  extremities  of  the  bone,  which  gradually  becomes 
more  and  more  solid  by  the  deposition  of  ossific  matter,  until  it 
becomes  a  perfect  bone  in  every  respect,  except  that  the  medullary 
canal  is  absent,  the  entire  bone  being  solid  and  consequently  less 
liable  to  break  at  that  point  than  at  any  other,  provided  the  ex- 
tremities have  been  properly  adjusted  and  retained  in  contact 
sufficiently  long  for  perfect  union  to  occur.  It  is  impossible  for  any 
surgeon  to  dress  a  fractured  limb  permanently,  directly  after  the 
accident  has  occurred,  without  applying  the  bandages  too  tight  for 
the  safety  of  the  limb  and  the  comfort  of  the  patient.  That  is  the 
great  danger  in  the  treatment  of  fractures,  and  the  reason  why  so 
many  deformities  and  false  joints  result  from  such  injuries.  If  you 
apply  a  roller  bandage  at  all,  which  I  seldom  do,  let  it  be  loose, 
otherwise,  in  three  or  four  hours  the  pain  will  be  excruciating,  and 
if  the  constriction  be  not  removed  it  may  produce  strangulation. 
After  dressing  the  limb  for  the  first  time,  always  leave  directions 
that  if  the  bandages  become  so  tight  as  to  produce  pain  they  should 
be  removed  or  divided  with  scissors,  and  the  splints  secured  by  the 
application  of  three  or  four  strips  about  an  inch  in  width.  At  the 
wrist  and  ankle-joints  the  bones  have  but  little  protection,  and  if 
the  splints  are  not  well  padded  they  not  only  produce  pain,  but  also 
ulceration  of  the  skin  and  great  subsequent  annoyance.  Com- 
pound fractures  are  more  dangerous  than  those  of  a  simple  char- 
acter. They  are  not  only  more  dangerous,  but  their  treatment  is 
more  tedious  and  difficult.  In  such  cases,  when  one  of  the  ex- 
tremities of  the  fractured  bone  protrudes  through  the  wound,  and 
cannot  be  replaced  without  resorting  to  great  force,  it  should  be  re- 
moved with  an  amputating  saw.  The  difficulty  experienced  in  such 
cases  results  from  the  violent  contraction  of  the  muscles.  Union  is 
much  more  certain  than  if  replaced  by  the  employment  of  force 
sufficient  to  seriously  injure  the  soft  parts.  The  wound  may  some- 
times be  enlarged  with  decided  advantage,  and  should  that  fail,  then 
adopt  the  treatment  already  recommended.  Suppose  you  were  to 
have  a  case  of  compound  fracture,  in  which  the  main  artery  of  the 
limb  was  wounded,  with  considerable  contusion  and  laceration  of 
the  soft  parts,  then  the  limb  should  be  amputated  as  soon  as  reaction 
occurs.  I  am  now  treating  a  case  of  a  gentleman  from  Knight's 


276          LECTURES  ON  PRACTICAL  SURGERY. 

Landing,  on  the  Sacramento  River,  whose  arm  was  terribly  lacerated 
by  a  threshing  machine.  If  I  had  seen  him  during  the  second 
stage,  or  before  inflammation  was  established,  I.  would  have  am- 
putated, but  as  seven  or  eight  days  had  elapsed  before  he  arrived  in 
San  Francisco,  I  determined  to  wait  until  suppuration  was  es- 
tablished, and  I  now  find  that  the  arm  can  be  saved,  provided  his 
general  health  does  not  suffer  from  the  profuse  discharge  inseparable 
from  so  extensive  a  wound.  The  skin  from  the  anterior  portion  of 
the  arm  from  the  shoulder  to  the  wrist  was  torn  off,  leaving  the 
flexor  muscles  and  tendons  all  exposed,  and  one  of  the  bones  of 
the  forearm  was  fractured.  The  brachial  artery  was  ligated.  The 
extensor  muscles  and  tendons  sloughed  and  the  radius  exfoliated. 
The  fracture  united  and  the  wound  healed,  although  the  hand,  in 
consequence  of  the  loss  of  the  muscles,  will  not  be  very  useful.  The 
phalanges  of  the  fingers  and  toes  are  very  liable  to  be  fractured, 
usually  as  the  result  of  blows  or  falls.  A  gentleman  of  this  city 
fractured  the  forefinger  of  the  right  hand  in  alighting  from  his 
buggy,  by  passing  it  between  the  dasher  and  the  iron  by  which  it  is 
surrounded.  I  treated,  in  the  United  States  Marine  Hospital,  a  case 
of  fracture  of  the  great  toe,  produced  by  falling  through  the  scuttle 
of  a  ship ;  the  patient  having  extended  his  feet  to  break  the  vio- 
lence of  the  fall,  the  great  toe  was  the  first  to  come  in  contact  with 
the  deck,  and  was  fractured.  Fractures  both  of  the  toes  and  fingers 
occur  more  frequently  from  direct  violence.  The  treatment  is  very 
simple.  After  reducing  the  fracture,  envelop  the  part  either  with 
cotton  or  lint,  and  then  apply  either  thin  pasteboard  or  blotting-paper, 
instead  of  wooden  splints,  as  the  former  are  less  painful^ind  equally 
effectual.  If  necessary,  a  small  wooden  splint  may  be  applied  ex- 
ternally and  secured  by  a  bandage,  applied  so  as  simply  to  retain  it 
in  a  proper  position.  I  sometimes  include  in  the  bandage  one  of 
the  fingers  or  toes  that  has  not  been  injured,  and  have  found  it  as 
good  a  splint  as  could  be  applied.  There  is  no  danger  of  deformity 
resulting  from  a  fracture  of  this  character,  unless  it  be  neglected. 
Always  interpose  cotton  or  lint  between  the  fingers  or  toes  to  prevent 
the  irritation  that  would  certainly  result  if  they  were  kept  in  contact 
without  the  intervention  of  the  substances  mentioned.  A  fracture 
of  the  metacarpal  bones  is  much  more  difficult  to  treat,  because  the 
flexor  muscles,  being  very  powerful,  have  a  tendency  to  draw  the 
outer  extremities  of  the  bones  forward  and  produce  a  deformity  on 


LECTURE    XXIII.  —  FRACTURES.  277 

the  back  of  the  hand.  In  consequence  of  this,  I  have  found  more 
difficulty  in  treating  fractures  of  the  metacarpal  bones  than  those  in 
any  other  location.  In  such  cases  the  splint  should  extend  from  the 
wrist  on  the  back  of  the  hand  to  the  extremity  of  the  fingers,  and  a 
compress  of  cotton  should  be  applied  over  the  point  of  the  fracture. 
The  bone  can  be  kept  straight  if  sufficient  pressure  is  made  upon 
the  back  of  the  hand  to  counteract  the  flexor  muscles.  A  compress 
of  cotton  is  preferable  to  one  of  any  other  material,  because  it  is  al- 
most impossible  to  produce  ulceration  of  the  skin  when  a  sufficient 
quantity  is  interposed  between  it  and  the  splint,  even  when  con- 
siderable pressure  is  made.  When  all  the  metatarsal  bones  are 
fractured  in  the  same  manner,  which  sometimes  occurs,  a  broad 
splint,  well  padded  with  cotton  to  prevent  ulceration,  should  be  ap- 
plied to  the  bottom  or  sole  of  the  foot,  and  secured  by  a  bandage  so 
as  to  prevent  displacement;  should  inflammation  supervene,  employ 
the  remedies  previously  recommended.  The  fibula  may  be  frac- 
tured either  by  direct  violence  or  by  the  foot  being  twisted  outwards 
with  sufficient  force;  the  fracture  usually  takes  place  about  an 
inch  and  a  half  above  the  lower  extremity  of  the  bone.  There  is 
seldom  much,  if  any,  displacement,  and  but  one  splint  should  be 
used  in  the  treatment.  This  splint  should  be  straight,  and  when  well 
padded  with  cotton,  should  be  applied  on  the  inner  or  tibial  side  of 
the  leg  and  secured  by  a  bandage  with  the  precautions  already  fre- 
quently recommended.  No  other  dressing  is  necessary,  and  if  the 
bandage  is  not  applied  sufficiently  tight  to  force  the  fibula  inward,, 
and  thereby  render  it  shorter  than  the  tibia,  no  deformity  can 
result.  Should  the  patient  be  dissatisfied  with  the  use  of  only  one 
splint,  Roe's  leg  splints  should  be  substituted,  which,  by  the  use  of 
crutches,  will  enable  the  patient  to  leave  his  bed  sooner  than  would 
be  prudent  provided  only  one  splint  had  been  applied. 

It  is  very  rare  that  both  the  tibia  and  fibula  are  fractured  at  the 
same  point.  The  fibula  is  usually  broken  near  the  ankle-joint,  and 
the  tibia  near  the  centre  or  even  above,  although  they  may  both  be 
broken  at  the  same  point  near  the  ankle.  In  a  case  of  that  character 
there  is  always  danger  of  anchylosis,  in  consequence  of  the  violence 
offered  to  the  articulating  surfaces  being  liable  to  be  followed  by 
inflammation.  In  such  cases  Roe's  leg  splints  should  be  applied, 
and  particular  attention  given  to  the. ankle-joint,  which  should  be 
moved,  after  the  third  week,  at  least  every  two  or  three  days,  to  pre- 
vent anchylosis. 


278  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE    XXIV. 

GENTLEMEN:  When  the  last  lecture  closed,  I  had  not  finished  dis- 
cussing fractures  of  the  leg.  Oblique  fra.ctures  of  the  tibia  are  ex- 
ceedingly difficult  to  treat  successfully,  and  some  eminent  surgeons 
believe  that  in  such  cases  there  is  almost  always  a  slight  shortening 
of  the  leg.  I  think  this  can  be  avoided  by  the  application  of  four 
splints.  The  posterior  is  intended  to  counteract  the  action  of  the 
muscles  on  the  posterior  portion  of  the  leg,  the  lateral  to  prevent 
either  an  external  or  internal  curvature,  and  the  anterior,  which, 
when  well  padded,  should  be  applied  to  the  tibia  with  a  compress 
over  the  superior  fragment  to  prevent  the  projection  of  that  extremity, 
which  almost  always  occurs  when  that  precaution  is  not  taken. 
You  have  all  seen  several  cases  of  oblique  fracture  of  the  tibia 
treated  in  the  hospital,  and  in  every  case  the  bone  united  without 
either  deformity  or  shortening.  Besides,  you  had  an  opportunity  of 
seeing  the  splints  applied  and  of  ascertaining  the  result.  When  the 
bones  of  the  leg  are  fractured  near  the  knee-joint,  I  always  place  the 
limb  upon  Roe's  double  inclined  plane,  and  apply  lateral  splints, 
unless  the  injury  is  so  near  the  knee  as  to  render  the  latter  un- 
necessary. In  compound  fracture  of  the  bones  of  the  leg  the  size 
and  position  of  the  wound  will  render  some  modification  in  the 
treatment  necessary.  Should  the  wound  be  over  the  tibia,  which 
is  usually  the  case,  the  posterior  splint  must  be  relied  upon  entirely 
to  counteract  the  gastrocnemii  muscles,  which,  if  not  controlled, 
produce  an  anterior  curvature  and  sometimes  a  displacement  suffi- 
cient to  render  it  difficult  for  union  to  occur.  When  the  splints 
recommended  cannot  be  obtained,  others  can  be  made  that  will 
answer  the  same  purpose,  out  of  stiff  pasteboard,  gutta-percha,  or 
sole  leather,  either  of  which,  when  cut  in  proper  shape,  and  softened 
by  the  application  of  warm  water,  can  be  moulded  to  the  shape  of 
the  limb,  and  when  padded  so  as  to  prevent  undue  pressure  upon 
the  most  prominent  points,  will  enable  you,  by  the  application  of  a 
common  roller  and  the  straps  usually  employed,  to  prevent  the  dis- 


LECTURE    XXIV. — FRACTURES.  279 

placement  of  the  bones  after  they  have  been  reduced.  The  wound 
should  be  covered,  at  first  with  cloths  wet  with  cold  water,  and 
after  the  period  at  which  inflammation  usually  occurs,  the  warm- 
water  dressing  should  be  substituted  to  hasten  the  cicatrization  of 
the  wound.  In  such  cases  the  bandage  should  be  so  put  on  that  the 
wound  can  be  dressed  without  disturbing  the  splints,  and  in  order 
to  give  support  to  the  wound,  a  compress  may  be  applied  and  se- 
cured by  a  strip  of  bandage  passed  over  and  tied  upon  the  posterior 
part  of  the  leg.  After  suppurative  inflammation  is  established,  sim- 
ple cerate  should  be  substituted  for  the  warm-water  dressing,  and 
secured  by  a  compress  of  cotton  and  a  strip  of  bandage  so  that  the 
dressings  will  not  adhere  to  the  ulcer,  which  can  then  be  exposed  with- 
out disturbing  the  splints. 

If  physicians  relied  more  on  their  own  common  sense  than  on  the 
rules  of  authorities  in  the  treatment  of  fractures,  there  would  not  be 
half  so  many  cases  of  deformity  resulting  from  such  injuries  as  are 
daily  presented.  I  would  as  soon  think  of  committing  suicide  as  of 
placing  an  oblique  fracture  of  the  tibia  in  an  ordinary  fracture-box, 
filled  with  either  sand,  sawdust,  or  any  of  the  other  substances  used 
for  that  purpose.  The  limb  should  always  be  kept  in  view,  so  that 
any  displacement  may  be  perceived  and  corrected  before  the  bone 
becomes  so  firmly  united  as  to  render  it  impossible.  When  the 
fracture-box  is  employed  in  such  cases,  the  limb  is  generally  and 
unfortunately  almost  always  deformed.  If,  however,  it  be  dressed 
so  that  its  position  can  be  ascertained,  should  the  dressings  be  de- 
ranged, either  by  accident  or  design,  they  can  be  replaced,  and  any 
permanent  difficulty  prevented.  Many  physicians,  but  I  cannot  call 
them  surgeons,  apply  the  starch  bandage  in  recent  fractures.  I 
have  known  them  to  be  applied  in  this  city  in  compound  fractures 
of  the  leg  the  next  day  after  the  receipt  of  the  injury.  It  is  always 
improper,  because  it  is  impossible  to  determine  how  much  tume- 
faction will  occur,  and  frequently,  when  the  bandage  is  removed, 
not  only  extensive  ulceration,  but  great  displacements,  will  be  found 
to  exist.  In  compound  fracture  always  leave  the  wound  exposed, 
dress  it  every  day,  and  then  you  will  feel,  if  any  unfavorable  symp- 
tom occurs,  that  the  case  has  been  treated  properly  and  that  you 
are  not  guilty  of  any  neglect.  Should  inflammation  occur,  if  the 
patient  be  in  full  health,  apply  leeches,  and  then  either  the  evapo- 
rating lotion  or  cold  irrigation,  according  to  the  violence  of  the  dis- 


280  LECTURES    ON    PRACTICAL    SURGERY. 

eased  action.  I  have  been  practicing  surgery  for  thirty  years,  and 
I  have  never  had  a  case  of  simple  fracture  in  which  ulceration  of 
the  skin  resulted  either  from  inflammation  or  from  the  improper 
pressure  either  of  the  bandages  or  splints,  except  in  the  first  case  I 
treated,  which  was  a  fracture  of  the  fore  and  middle  fingers  of  the 
left  hand.  I  was  taught  by  a  very  distinguished  surgeon  that  if  a 
bandage  was  properly  applied  the  vitality  of  the  part  would  not  be 
destroyed,  even  by  the  use  of  a  force  equal  to  ten  horse-power. 
Both  the  fingers  were  tightly  bandaged,  and  splints  applied  ;  at  the 
expiration  of  a  week,  when  they  were  removed,  nothing  remained 
but  the  skin  and  bones,  and  I  had  the  credit  of  amputating  two 
fingers  which  should  have  been  saved.  This  case  taught  me  a  val- 
uable lesson.  I  saw  by  the  result  the  danger  of  applying  tight 
bandages  at  an  early  period,  and  have  since  always  carefully  avoided 
them.  The  tibia  may  be  fractured  near  the  upper  extremity,  and 
even  at  the  head,  which  is  always  a  serious  injury,  in  consequence 
of  the  danger  that  the  knee-joint  may  become  implicated,  and  when 
inflammation  does  occur,  the  best  possible  result  that  can  be  obtained 
is  anchylosis  of  the  j.oint.  In  such  cases  place  the  lirnb  upon  a  dou- 
ble inclined  plane,  either  Roe's  splint  or  the  one  which  I  employ  in 
fractures  of  the  thigh  in  the  hospital,  either  with  or  without  lateral 
splints,  according  to  the  character  of  the  injury. 

Fracture  of  the  patella,  although  not  very  common,  is  interesting, 
in  consequence  of  the  difficulty  experienced  in  its  treatment.  If  a 
fracture  of  this  character  is  not  managed  skilfully,  the  usefulness  of 
the  limb  is  permanently  impaired.  The  patella  may  be  fractured 
either  transversely  or  longitudinally;  it  is  generally  simple.  I  have 
treated  five  cases  in  this  city,  and  they  were  all  simple  and  trans- 
verse. Many  surgeons  believe  that  in  such  cases  bony  union  cannot 
take  place.  From  the  result  of  my  experience,  I  am  entitled  to  say 
that  it  can  and  does  frequently  occur  when  cases  are  properly  man- 
aged. The  patella,  as  you  are  all  aware,  forms  the  anterior  portion 
of  the  knee-joint ;  it  is  lined  on  the  inside  by  the  synovial  mem- 
brane, and  when  a  bone  is  fractured  within  the  capsule  of  a  joint, 
as  the  patella  and  neck  of  the  thigh-bone,  it  is  always  difficult  to 
effect  bony  union,  but  still  it  does  sometimes  take  place.  In  conse- 
quence of  the  difficulty  experienced  .in  the  treatment  of  such  cases, 
they  have  received  great  attention,  and  numerous  methods  have 
been  adopted  for  the  purpose,  if  bony  union  should  not  take  place, 


LECTURE    XXIV.  —  FRACTURES.  281 

to  render  the  separation  of  the  fragments  as  small  as  possible.  M. 
Malgaigne,  a  distinguished  surgeon  of  Paris,  invented  an  instrument, 
which  consists  of  double  hooks  connected  by  a  screw,  after  being 
passed  through  the  skin  are  inserted  into  each  fragment,  then  they 
are  approximated  and  retained  in  contact  with  the  screw.  I  have 
succeeded  with  this  instrument ;  but  the  most  satisfactory  result  has 
been  obtained  by  the  use  of  the  ring,  recommended  by  Prof.  Paul 
F.  Eve,  of  Nashville,  Tennessee.  The  fragments  should  be,  in  the 
first  place,  approximated  and  retained  in  that  position  by  the  appli- 
cation of  adhesive  plaster,  and  then  the  part  should  be  covered  with 
cotton  batting,  over  which  the  ring  should  be  applied  and  secured 
by  the  straps  and  buckles  which  are  attached.  By  the  application 
of  this  instrument  the  fragments  can  be  brought  and  retained  directly 
in  contact,  and  if  the  limb  be  extended  and  kept  in  that  position  for 
four  or  five  weeks,  the  result  will  be  satisfactory.  To  the  genius  of 
Prof.  Eve,  once  my  competitor,  we  are  indebted  for  this  simple  and 
valuable  instrument,  and  if  he  had  never  made  any  other  contribu- 
tion to  surgery,  it  alone  would  entitle  him  to  the  gratitude  of  the 
profession,  and  transmit  his  name  to  posterity  as  one  of  the  benefac- 
tors of  mankind.  * 

After  the  application  of  the  ring  the  limb  should  be  kept  extended, 
and  after  the  third  week  the  knee  should  be  partially  flexed ;  this 
should  be  repeated  every  three  or  four  days,  until  union  has  taken 
place.  Wherever  there  is  a  hardware  store,  and  a  shoemaker  or  a 
saddler,  the  ring  can  be  procured  ready  for  application  in  a  few 
hours.  Should  you  be  required  to  treat  a  case  of  this  character 
when  it  is  impossible  to  obtain  this  instument,  then  you  may  either 
apply  a  figure-of-eight  bandage  or  a  roller  both  above  and  below 
the  fragments,  and  approximate  them  by  strips  of  cloth  passed  under 
both  on  each  side  of  the  knee,  and  tied  sufficiently  tight  to  bring 
the  fractured  surfaces  in  contact,  which  should  be  tightened  when 
rendered  necessary  by  the  stretching  of  the  bandages. 

The  femur,  notwithstanding  its  great  strength,  is  occasionally  frac- 
tured. In  mature  age  fractures  occur  more  frequently  at  the  lower 
third,  in  children  near  the  middle,  and  in  old  people  at  the  neck 
or  near  the  upper  extremity  of  the  bone.  In  one  hundred  and 
twenty-six  cases  of  fracture  of  the  thigh,  the  neck  of  the  bone  was 
fractured  in  twenty-six,  and  that  is  about  the  ordinary  occurrence  of 
such  cases.  The  next  point  to  be  considered  is  the  question — can 


282 


LECTURES    ON    PRACTICAL    SURGERY. 


bony  union  occur  in  such  cases  ?  Malgaigne,  in  his  work  on  surgery, 
says  that  he  has  investigated  the  subject  carefully,  and  that  three 
cases  have  come  within  his  knowledge  in  which  bony  union  of  the 
neck  of  the  thigh-bone  did  occur.  Smith,  in  his  work,  has  reported 
seven  cases.  This  bone  may  be  broken  at  any  point.  Fig.  62 
(page  271),  represents  a  fracture  of  the  neck  of  the  thigh-bone  within 
the  capsule.  Whenever  fracture  takes  place  within  the  capsule  it 
is  said  to  be  a  fracture  of  the  neck,  and  I  have  given  the  result  of 
all  the  cases  that  have  occurred  both  in  Europe  and  America.  The 
fracture  may  be  either  within  the  capsule,  near  its  attachment  below 
the  trochanter  major,  or  indeed  at  any  point  from  the  trochanters  to 
the  condyles.  It  is  interesting  to  see  the  effort  which  nature  some- 
times makes  to  restore  the  usefulness  of  the  bone  after  such  an  injury. 
One  of  the  most  extraordinary  specimens  connected  with  injuries 
of  this  part  occurred  in  the  neck  of  a  thigh-bone  fractured 
near  the  trochanter  major;  during  the  existence  of  the  reparative 
process,  a  probe  or  process  of  bone  extending  from  the  neck  to  the 
shaft  several  inches  below  was  produced,  rendering  the  occurrence  of 
the  same  difficulty  almost  impossible,  as  the  bone  would  fracture  at 


FIG.  64. 


some  other  point  sooner  than  at  the  one  originally  injured.  The 
knowledge  of  the  correct  method  of  treating  fractures  of  this  kind 
is  very  important,  and  I  think  very  easily  acquired.  Various 
methods  have  been  adopted  and  advocated,  but  the  most  simple  is 
the  best,  and  should  always  be  selected.  What  is  called  a  "  fracture 
chair"  is  an  exceedingly  convenient  double  inclined  plane,  but  I  do 
not  think  that  it  possesses  any  advantages  over  the  one  used  at  the 


LECTURE    XXIV.  —  FRACTURES    OF    THE    THIGH.  283 

County  Hospital,  which  is  made  of  two  pieces  of  inch  plank,  two 
feet  long  and  about  one  inch  in  width,  secured  as  appears  in  the  plate ; 
a  pillow  should  be  placed  upon  each  side.  This  is  the  instrument 
that  was  used  by  Dupuytren  in  all  fractures  of  this  bone.  Desault's 
splint,  modified  by  Boyer,  was  abandoned  by  the  latter  long  before 
his  death,  in  consequence  of  the  ulceration  of  the  groin  and  foot 
inseparable  from  its  application.  If  you  wish  to  make  extension 
and  counterextension,  use  what  is  called  the  hospital  splint.  The 
extension  should  be  made  by  adhesive  strips  upon  each  side  of  the 
leg,  which  should  be  previously  shaved,  and  with  them  there  is  no 
danger  of  producing  ulceration  either  of  the  instep  or  the  heel, 
which  almost  always  results  if  bandages  are  employed  for  that 
purpose.  The  upper  extremity  of  the  splint  is  secured  by  a  strap 
buckled  around  the  waist,  which  constitutes  the  counterextension. 
This  is  decidedly  superior  either  to  Desault's  or  Physick's  splint, 
which  was  formerly  almost  universally  employed.  This  extended 
to  the  axilla,  and  the  patient  was  confined  upon  his  back  in  the 
most  uncomfortable  position  that  can  be  imagined.  In  order  to  pre- 
vent the  curvature  of  the  thigh  outwards,  this  splint  is  all  that  is 
necessary.  It  extends  from  the  knee  to  the  pelvis,  and  should  be 
secured  as  will  be  hereafter  directed.  On  the  seventh  day  after  the 
receipt  of  the  injury,  apply  a  bandage  from  the  instep  to  the  hip, 
the  limb  being  extended  by  an  assistant  to  the  proper  length.  The 
splint  exhibited  should  be  applied  to  the  outer  side  of  the  thigh, 
and  shorter  splints  upon  the  inner  and  superior  surfaces  of  the  limb  ; 
when  secured  by  a  roller  bandage,  three  strips  should  be  placed  over 
it,  so  that  the  splints  can  be  retained  in  a  proper  position  by  tight- 
ening them  as  often  as  may  be  necessary,  which  will  render  the  re- 
moval of  the  bandage  and  the  disturbance  of  the  relation  of  the 
bones  unnecessary.  Then  place  the  limb  upon  the  double  inclined 
plane  on  a  large  pillow.  If  the  patient  be  young,  the  use  of  the  limb 
will  be  recovered  with  less  deformity  and  less  suffering  than  by  any 
other  treatment  that  can  be  adopted.  The  splints  should  be  well 
padded  with  cotton ;  the  bandages  should  not  be  too  tight ;  and  if 
these  precautions  are  taken  you  will  not  find  any  more  difficulty  in 
treating  fractures  of  the  thigh  than  those  of  any  other  bone.  In 
cases  of  compound  fracture  it  will  be  necessary  to  dress  the  wound 
every  day ;  therefore  the  bandage  should  be  put  on  in  such  a  man- 


284  LECTURES    ON    PRACTICAL    SURGERY. 

ner  as  to  leave  the  wound  exposed,  and  after  the  application  of  lint, 
covered  with  simple  cerate,  a  compress  of  cotton  should  be  applied 
and  secured  by  a  broad  strip,  which  should  be  tied  on  the  opposite 
side  of  the  leg.  Always  arrange  the  dressings  in  such  a  manner 
that  the  wound  can  be  examined  every  day,  so  as  to  ascertain  its 
condition.  When  a  fracture  of  the  thigh  is  treated  in  this  manner 
it  is  impossible  for  the  limb  to  be  deformed.  There  may  be  a  slight 
shortening,  and  according  to  the  best  authorities  you  should  expect 
three-quarters  of  an  inch.  If  the  diminution  in  the  length  of  the  limb 
is  greater,  you  may  feel  that  you  have  not  treated  the  case  skilfully,  un- 
less it  be  one  in  which  there  existed  great  contusion,  or  laceration  fol- 
lowed by  violent  inflammation,  which  rendered  it  impossible  to  get  a 
better  result.  But  if  the  fracture  be  oblique  and  simple,  should  the 
shortening  of  the  limb  be  greater  than  an  inch,  the  result  should  be 
considered  very  unsatisfactory.  Dupuytren,  who  was  surgeon-in- 
chief  to  the  Hotel  Dieu,  in  Paris,  and  was  the  greatest  man  at  that 
time  in  the  profession,  always  used  the  short  splints  and  the  double 
inclined  plane,  and  with  extraordinary  success.  We  should  always  be 
governed  by  the  opinions  of  such  men.  An  experienced  surgeon 
can  apply  either  Desault's  or  Physick's  splints,  and  the  result  will  be 
satisfactory,  but  a  young  man  may  find  after  he  has  kept  his  patient 
on  his  back  with  extension  and  counterextension  for  two  or  three 
months,  that  the  knee-joint  either  moves  with  difficulty  or  is  entirely 
anchylosed ;  but  when  the  short  splints  and  the  double  inclined 
plane  are  applied,  the  knee-joint  after  the  third  week  can  be  moved 
every  day  without  disturbing  the  dressings,  and  such  a  complication, 
which  is  always  serious,  is  rendered  impossible.  In  Hamilton's 
able  work  on  fractures  you  will  find  every  successful  method  of 
treatment  described  by  one  perfectly  familiar  with  the  subject,  but  when 
you  engage  in  practice,  you  will  soon  be  convinced  that  the  double 
inclined  plane  and  short  splints  are  generally  better  than  a  more 
complicated  apparatus.  In  the  treatment  of  fractures  of  the  thigh 
in  children,  a  large  pillow  forms  as  good  a  double  inclined  plane  as 
can  be  made,  which,  with  the  splints  recommended,  will  always  pre- 
vent both  shortening  and  deformity.  There  is  another  very  im- 
portant fact  connected  with  the  treatment  of  fractures  with  which 
you  should  be  familiar,  and  that  is,  if  the  limb  be  too  tightly  ban- 
daged it  becomes  atrophied  to  such  an  extent  that  there  is  really  not 


LECTURE    XXIV. — FRACTURES.  285 

sufficient  vitality  in  the  part  to  produce  any  union  of  the  bone.  I 
have  frequently  seen  Dupuytren,  when  he  found  that  the  limb  was 
becoming  atrophied,  which  sometimes  occurs  even  when  too  much  pres- 
sure has  not  been  made,  have  the  splints  removed,  and  after  having 
the  limb  washed  with  warm  water,  place  it  upon  a  pillow  and  allow 
it  to  remain  there  until  it  acquired  its  original  size  before  reap- 
plying  the  splint;  And  in  some  cases  it  becomes  necessary  to  re- 
move the  splints  two  or  three  times  in  order  to  avoid  a  false  joint, 
or,  in  other  words,  to  favor  the  deposition  of  a  sufficient  quantity  of 
lymph  and  ossific  matter,  to  produce  a  perfect  union  of  the  ex- 
tremities of  a  fractured  bone. 


286  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   XXV. 

GENTLEMEN  :  At  my  last  lecture  the  hour  expired  before  I 
reached  the  subject  of  fractures  of  the  neck  of  the  thigh-bone.  In 
their  treatment,  whether  intra  or  extra-capsular,  the  same  course 
should  be  pursued  which  has  been  recommended  in  fractures  of  the 
lower  extremity  or  shaft  of  the  bone,  and  for  the  best  results  which 
I  have  obtained  in  such  cases,  I  am  indebted  to  the  use  of  the  double 
inclined  plane.  After  placing  cotton  batting  between  the  feet,  they 
should  be  secured  firmly  together  by  a  roller  bandage,  and  then  the 
extremities  should  be  placed  upon  the  double  inclined  plane,  after 
applying  the  external  splint,  extending  from  the  pelvis  to  the  knee, 
and  then  if  bony  union  takes  place  at  all,  it  is  impossible  for  the 
limb  to  be  shortened.  In  one  case,  treated  in  that  manner,  there 
was  no  perceptible  shortening,  and  I  think  if  bony  union  ever  does 
take  place,"  after  such  an  injury,  it  then  occurred. 

Fingers. — Fractures  of  the  fingers  may  be  either  simple  or  com- 
pound. I  have  frequently  met  with  both.  After  reducing  the  frac- 
ture, cover  the~ finger  with  wet  lint,  and  then  apply  thin  pasteboard 
splints  or  common  blotting-paper,  which  will  answer  equally  well, 
then  a  bandage,  so  as  to  retain  the  extremities  of  the  bone  in  contact. 
Always  apply  the  bandage  loosely,  until  you  are  certain  that  all  the 
swelling  that  can  occur  has  taken  place.  After  the  first  two  weeks 
the  splints  should  be  removed  at  least  once  a  week,  and  the  finger 
should  be  flexed  and  extended  in  order  to  prevent  anchylosis,  par- 
ticularly if  the  patient  be  a  laboring  man  and  beyond  the  middle 
age.  If,  in  such  cases,  this  precaution  be  neglected,  anchylosis  oc- 
curs in  four  or  five  weeks.  Every  year  I  am  consulted  by  persons 
from  the  interior  who  have  either  partial  or  complete  anchylosis  of  the 
fingers,  the  result  of  fractures  of  them  or  of  the  forearm ;  or  even  from 
whitlow,  in  consequence  of  allowing  the  hand  to  remain  too  long  either 
in  splints,  or  from  neglecting  to  move  them  sufficiently  often  to  pre- 
vent a  difficulty  of  this  character.  In  such  cases  give  an  anaesthetic 
and  flex  the  joints  by  force,  and  then  by  using  the  hand  afterwards, 


LECTURE    XXV. — FRACTURES    OF    RADIUS.  287 

it  may,  in  a  short  time,  become  as  useful  as  before  the  receipt  of  the 
injury.  After  the  fracture  has  united,  I  generally  confine  the  finger 
that  was  injured  to  one  that  is  healthy,  and  direct  the  patient  to  use 
the  hand,  and  that  will  prevent  the  occurrence  of  anchylosis. 

The  metacarpal  bones  may  also  be  fractured.  Some  years  ago  I 
treated  a  man  in  whom  all  the  metacarpal  bones  were  fractured  by 
striking  his  antagonist's  head,  which  rested  against  a  hogshead  of 
sugar.  The  blow  was  so  violent  that  something  had  to  yield,  and 
the  bones  of  the  cranium  being  more  resistant  than  those  of  the  hand, 
the  latter  were  fractured.  In  such  a  case  you  should  make  sufficient 
extension  and  counterextension  to  place  the  extremities  in  apposi- 
tion, and  then  they  should  be  retained  thus,  by  placing  on  the  back 
of  the  hand  a  splint,  which  should  extend  from  above  the  wrist  to 
the  extremity  of  the  fingers.  Should  any  difficulty  be  experienced 
in  keeping  the  bones  straight,  by  reason  of  the  action  of  the  flexor 
muscles  of  the  arm,  a  compress  of  cotton  should  be  placed  both  above 
and  below,  as  it  is  never  desirable  to  make  pressure  directly  over  the 
seat  of  the  fracture,  for  fear  of  producing  ulceration  of  the  skin,  for 
nothing  promotes  absorption  so  rapidly  and  certainly  as  pressure. 
You  must  be  exceedingly  careful  in  the  management  of  such  cases, 
in  order  to  prevent  deformity.  The  flexor  muscles,  being  much  more 
powerful  than  the  extensors,  have  a  tendency  to  draw  the  fingers  and 
distal  extremities  of  the  metacarpal  bones  forward,  and  if  this  be 
not  counteracted,  an  anterior  curvature  will  result. 

One  of  the  most  difficult  fractures  to  treat  is  that  of  the  lower 
extremity  of  the  radius.  More  cases  of  deformity  result  from  this 
than  from  any  other  fracture.  It  is  not  difficult  to  recognize,  although 
it  is  often  mistaken  for  dislocation  of  the  wrist-joint.  Dupuytren 
believed  and  taught  that  the  wrist-joint  was  never  dislocated,  or, 
in  other  words,  that  the  ulna  is  never  dislocated  without  a  fracture 
of  the  lower  extremity  of  the  radius.  I  formerly  entertained  the 
same  opinion,  but  I  recently  met  with  a  case  which  convinced  me 
that  a  dislocation  of  the  wrist-joint  may  occur  without  fracture, 
although  very  rarely.  This  accident  almost  always  results  from  fall- 
ing upon  the  hands,  and  takes  place  about  an  inch  or  an  inch  and  a 
half  above  the  wrist-joint.  The  position  of  the  hand  is  entirely 
changed,  being  turned  outward,  and  if  the  difficulty  is  not  recog- 
nized and  properly  treated,  a  permanent  deformity  will  result.  The 
lower  extremity  of  the  radius  may  be  fractured  either  obliquely  or 


288          LECTURES  ON  PRACTICAL  SURGERY. 

transversely.  The  former  may  include  only  a  portion  of  the  bone, 
and  when  the  styloid  process  only  is  detached  it  is  called  Barton's 
fracture.  It  frequently  occurs,  and  from  this  and  other  oblique  frac- 
tures deformity  of  the  limb  is  much  more  liable  to  occur  than  from 
those  of  a  transverse  character,  which  are  much  more  easily  reduced 
and  retained  in  a  proper  position  until  union  takes  place. 

In  fractures  of  the  lower  extremity  of  the  radius,  if  a  proper  course 
be  pursued,  deformity  may  be  prevented.  Yet  you  should  always 
take  the  precaution  to  inform  the  patient  of  the  difficulties  to  be  over- 
come, so  that  if  a  slight  deformity  should  result  from  the  injury,  you 
may  avoid  censure.  In  this  fracture  always  apply  the  pistol  splint, 
because  it  is  the  only  one  with  which  it  can  be  treated  successfully. 
In  such  cases  the  hand  is  thrown  inwards,  and  the  lower  extremity 
of  the  ulna  becomes  very  prominent,  which  peculiarity,  in  a  large 
proportion  of  the  cases  of  this  character,  remains  after  the  radius 
has  united.  The  pistol  splint  derives  its  name  from  its  outline.  It 
should  be  applied  to  the  external  portion  of  the  forearm  and  hand, 
and  should  be  well  padded  and  secured  by  a  roller  bandage.  I 
frequently  apply  this  splint  upon  the  inner  side  of  the  arm,  although 
I  do  not  advise  it,  in  consequence  of  the  unpleasant  effects  which 
are  sometimes  produced  by  pressure  made  upon  the  median  nerve, 
which,  besides  being  exceedingly  painful,  is  sometimes  followed  by 
partial  paralysis  of  the  hand.  I  have  seen  a  case,  during  the  last 
year,  in  which  paralysis  of  the  hand  with  anchylosis  of  the  fingers 
and  wrist-joint,  which  I  think  will  be  permanent,  were  produced  by 
applying  a  splint  upon  the  anterior  part  of  the  arm,  without  padding 
it  sufficiently  to  afford  the  proper  protection. 

Simple  fractures  of  the  forearm,  even  when  both  the  bones  are 
broken,  are  easily  managed.  You  can  always  ascertain  when  the 
fracture  is  reduced,  and  then  splints*  should  be  applied  sufficiently 
wide  to  prevent  the  approximation  and  bending  of  the  radius  and 
ulna,  which  would  destroy  the  power  both  of  pronation  and  supi- 
nation  of  the  hand.  To  render  that  impossible  I  generally  apply 
a  compress  about  the  size  of  the  little  finger,  composed  of  cloth, 
paper  or  even  lint,  upon  the  outer  side  of  the  arm  between  the 
bones,  over  which  the  splint  should  rest,  and  be  secured  by  the 
roller  bandage  and  three  strips.  The  bones  of  the  forearm  may  be 
broken  at  the  same  or  different  points,  yet  the  same  course  of  treat- 
ment should  be  adopted.  You  should  be  careful  in  such  cases  never 


LECTURE    XXV.  —  FRACTURES    OF    ELBOW.  289 

to  allow  the  splints  to  extend  beyond  the  extremity  of  the  meta- 
carpal  bones,  so  that  the  motion  of  the  fingers  is  not  disturbed  ; 
then  even  in  persons  advanced  in  life  there  will  be  no  danger  of  an- 
chylosis, which  frequently  occurs  even  in  simple  fracture  of  the  arm, 
when  the  splints  have  extended  to  the  extremities  of  the  fingers  and 
have  been  allowed  to  remain  too  long. 

When  the  bones  of  the  forearm  are  fractured  near  the  elbow-joint, 
the  trough  splint,  made  either  of  pasteboard,  gutta-percha,  or  what 
is  much  better,  of  felt,  should  be  applied  and  secured  in  such  a 
manner  as  to  keep  the  fragments  in  apposition  and  sufficiently  at 
rest  to  secure  bony  union.  After  the  third  week  the  splint  should 
be  removed,  and  the  arm  flexed  and  extended  so  as  to  prevent  an- 
chylosis of  the  elbow-joint,  which  often  occurs  and  is  one  of  the 
most  serious  complications  that  could  follow.  When  the  olecranon 
process  is  fractured  and  complicated  with  dislocation,  the  injury  is 
very  serious,  and  even  with  the  best  management  will  sometimes  be 
followed  by  anchylosis  of  the  elbow-joint.  I  treated  a  case  of  this 
character  a  few  weeks  ago,  in  which  after  a  fracture  of  the  olecranon 
the  forearm  was  kept  in  extension  unnecessarily  long  after  the 
receipt  of  the  injury.  The  fracture  had  united,  but  the  elbow  was 
straight  and  the  joint  stiff,  which  rendered  the  limb  almost  useless. 
In  that  case  I  gave  the  patient  chloroform,  flexed  the  joint  until  the 
forearm  was  at  a  right  angle  with  the  arm,  and  retained  it  in  that 
position  for  four  or  five  days ;  I  then  flexed  and  extended  it  sev- 
eral times,  and  repeated  this  for  three  or  four  days  until  the  motion 
of  the  joint  was  restored,  and  the  arm  as  useful  as  before  the  injury. 
About  the  same  time  I  treated  a  case  of  fracture  of  the  coronoid 
process  with  dislocation,  which  I  could  not,  after  it  was  reduced, 
retain  in  a  proper  position  without  securing  the  forearm  to  the 
arm  by  a  roller  bandage,  which  was  continued  for  six  or  eight  weeks. 
This  was  one  of  the  most  difficult  and  annoying  cases  I  ever  treated, 
yet  I  have  the  satisfaction  to  know  that  the  result  was  equally  grat- 
ifying both  to  myself  and  patient. 

When  the  olecranon  process  is  fractured,  the  arm  should  be  kept 
straight  for  three  weeks,  and  then  flexed  and  extended  occasionally 
or  placed  in  a  position,  if  anchylosis  is  unavoidable,  to  render  it  useful. 
In  fractures  both  of  the  olecranon  process  and  the  condyles  or  lower 
extremities  of  the  humerus,  the  splint  exhibited,  Fig.  65,  is  the  one  I 
usually  apply,  because  when  reduced,  the  bones  can  be  retained 

19 


290          LECTURES  ON  PRACTICAL  SURGERY. 

more  easily  than  by  any  other  splint,  and  the  position  is  the  one 
most  desirable  should  anchylosis  result.  This  splint  is  made  of  felt, 
yet  one  just  as  useful  can  be  made  of  gutta-percha  or  pasteboard, 
cut  into  a  suitable  shape.  After  being  softened  by  soaking  in  hot 
water,  it  should  be  applied  to  the  limb  when  in  a  proper  position, 

FIG.  65. 


and  secured  by  a  roller  bandage.  In  two  or  three  hours  either 
pasteboard  or  gutta-percha  will  harden  so  as  to  retain  its  shape,  and 
will  have  sufficient  strength  to  keep  the  extremities  of  the  bones  in 
contact.  Both  pasteboard  and  felt  are  cheaper  than  gutta-percha, 
and  often  much  more  serviceable,  as  the  latter  is  apt  to  be  rotten 
when  obtained,  and  always  soon  becomes  brittle  or  loses  its  elas- 
ticity by  heat  and  expansion. 

The  lower  extremity  of  the  humerus  is  sometimes  crushed  or  in- 
jured so  that  one  or  both  of  the  condyles  may  be  detached,  and  it  is 
always  difficult  in  such  cases  after  the  parts  have  become  swollen 
to  ascertain  the  extent  and  true  character  of  the  lesion.  In  such 
cases  the  extremity  should  be  placed  upon  a  pillow,  and  evaporating 
lotions  applied  until  the  swelling  subsides,  when  the  fracture  should 
be  reduced  and  the  trough  splint  applied.  The  case  is  subsequently 
treated  like  a  fracture  of  the  olecranon.  Take  the  precaution  always 
to  apprise  the  patient  and  his  friends  of  the  serious  character  of  the 
injury,  and  particularly  of  the  danger  of  anchylosis,  and  in  this 
manner  you  may  avoid  censure ;  should  it  occur,  the  result  would 
be  unsatisfactory. 

Fractures  of  the  humerus  may  take  place  at  any  point  from  the 
condyles  to  the  neck,  and  they  may  be  either  transverse  or  oblique. 
When  the  bone  is  fractured  above  the  insertion  of  the  latissimus 
dorsi  and  pectoralis  major  muscles,  it  is  called  a  fracture  of  the 


LECTURE    XXV. — FRACTURES    OP    THE    CLAVICLE.         291 

neck  of  the  humerus;  in  such  cases  the  lower  fragment  of  the  bone 
is  drawn  towards  the  axilla  by  these  powerful  muscles,  and  should 
their  action  not  be  overcome,  deformity  might  result  even  from  a 
fracture  of  that  character,  particularly  as  the  supraspinatus  has  a 
tendency  to  draw  the  superior  fragment  outward.  Three  splints 
will  usually  be  found  necessary  in  the  treatment  of  fractures  of  the 
arm,  either  of  the  shaft  or  neck.  The  external  should  be  suffi- 
ciently long  to  reach  from  the  acromion  process  to  the  elbow-joint. 
Before  it  is  applied,  a  strip  of  cloth  three  inches  wide  and  three 
yards  in  length  should  be  secured  by  its  centre  to  the  upper  ex- 
tremity of  the  splint  with  three  or  four  ordinary  tacks.  This  splint 
should  be  applied  upon  the  external  side  of  the  arm,  and  shorter 
splints  upon  the  anterior  and  inner  surfaces.  After  they  have  been 
secured  by  a  roller  bandage,  the  bandage  secured  to  the  upper  ex- 
tremity of  the  long  splint  should  be  passed  to  the  opposite  side  of 
the  body,  and  three  strips  applied  as  in  fractures  of  the  thigh,  to 
remove  the  necessity  of  disturbing  the  dressings  too  frequently 
should  the  bandages  become  loose.  By  adopting  this  course  you 
will  never  have  the  slightest  deformity.  Let  the  external  splint 
extend  above  the  upper  extremity  of  the  humerus,  and  if  well  se- 
cured it  is  impossible  for  deformity  to  result  from  this  injury. 
After  the  application  of  the  splints  as  directed,  place  the  arm  in  a 
sling ;  it  is  seldom  necessary  for  the  patient  to  remain  in  a  recum- 
bent position. 

Fractures  of  the  clavicle  are  very  common ;  they  generally  occur 
in  the  middle  external  third  or  near  the  acromial  curvature.  They 
may  result  either  from  direct  or  indirect  violence.  A  fall  upon  the 
shoulder  is  a  very  common  cause.  The  weight  of  the  body  being 
thrown  upon  the  clavicle,  it  frequently  yields.  When  this  bone  is 
fractured  near  the  outer  third,  the  external  extremity  is  usually  the 
most  prominent,  or  rides  over  the  internal,  in  consequence  of  the 
action  of  the  supraspinatus,  but  when  fractured  near  the  sternum 
the  internal  fragment  is  usually  the  most  prominent,  in  consequence 
of  the  attachment  of  the  sterno-cleido-mastoid  to  that  portion.  The 
method  of  treatment  in  such  cases  is  to  bring  the  fractured  ex- 
tremities in  apposition  by  drawing  the  shoulders  backwards,  and 
then  to  prevent  displacement  a  compress  an  inch  in  thickness  should 
be  applied  over  the  seat  of  the  injury,  and  secured  by  the  applica- 
tion of  three  or  four  long  adhesive  strips  about  an  inch  in  width, 


292  LECTURES    ON    PRACTICAL    SURGERY. 

and  applied  with  sufficient  force  to  prevent  displacement.  Shoulder- 
braces  or  handkerchiefs  arranged  so  as  to  answer  the  same  purpose 
should  then  be  applied,  which  can  be  tightened  by  the  bandage  which 
connects  them  as  may  be  necessary.  The  arm  should  then  be  raised 

FIG.  66. 


and  thrown  backwards  and  retained  in  that  position  by  a  broad 
bandage  which  passes  over  the  shoulder,  and  an  ordinary  sling  to 
support  the  hand.  The  complicated  bandages  formerly  in  vogue 
were  entirely  useless,  as  it  was  impossible  to  apply  them  in  such  a 
manner  as  to  fulfil  the  indications. 


LECTURE    XXV.  —  FRACTURES.  293 

When  the  ribs  are  fractured  respiration  is  difficult,  and  the  patient 
sometimes  has  a  troublesome  cough,  with  bloody  expectoration.  I 
shall  always  recollect  the  first  case  of  this  character  I  treated.  The 
man's  name  was  Davis ;  he  was  both  large  and  fat,  and  sustained  the 
injury  by  falling  upon  a  stone  from  a  chaise  which  was  upset  by  a 
careless  driver.  I  found  him  breathing  with  great  difficulty,  with 
considerable  haemorrhage  from  the  lungs.  I  recollected  that  Professor 
Dudley  directed  us  always  in  such  cases  to  apply  a  tight  bandage  so 
as  to  paralyze  the  action  of  the  respiratory  muscles,  which  I  did  ef- 
fectually by  passing  his  wife's  apron  around'  the  chest  and  securing 
it  firmly  with  a  coarse  needle  and  thread.  In  half  an  hour  after 
the  application  of  the  bandage  the  patient  was  relieved,  in  con- 
sequence of  the  abdominal  muscles  being  forced  to  relieve  those  of 
the  chest.  The  haemorrhage  from  the  lungs  soon  subsided,  and  his 
recovery  was  both  rapid  and  satisfactory.  Should  an  apron  not  be 
convenient,  take  a  strip  of  strong  cotton  cloth  from  twelve  to  sixteen 
inches  wide,  or  a  corset,  and  apply  either  so  firmly  as  to  approximate 
and  retain  in  contact  the  fractured  extremities  of  the  ribs ;  it  should 
be  tightened  as  often  as  may  be  necessary  to  keep  the  injured  parts 
entirely  at  rest. 

Fractures  of  the  inferior  maxillary  bone  rarely  occur  either  at 
the  neck  or  angle,  but  very  frequently  near  the  chin.  When  this 
accident  occurs  near  the  centre  of  the  bone,  it  is  sometimes  exceed- 
ingly difficult  to  keep  the  extremities  both  in  apposition  and  at  rest. 
Some  recommend  for  that  purpose  a  gutta-percha  splint,  moulded 
when  hot  into  the  proper  shape;  this  I  have  used,  but  I  prefer  the 
four-tailed  bandage.  With  it  you  can  without  difficulty  keep  the 
fragments  in  a  proper  position,  and  give  less  annoyance  to  the  pa- 
tient. After  the  application  of  the  bandage,  the  patient  should 
neither  talk  much  nor  take  solid  food,  as  either  would  have  a  ten- 
dency to  displace  the  extremities  of  the  bone  and  prevent  union. 

The  bandage  should  be  applied  sufficiently  tight  to  bring  the 
teeth  in  contact,  and  to  retain  them  in  that  position  long  enough  for 
union  to  occur.  Should  it  be  difficult  both  by  a  compress  and  band- 
age to  prevent  motion,  it  has  been  recommended  and  practiced  to 
fix  the  bone  by  passing  a  silver  wire  around  a  tooth  of  either  frag- 
ment, and  by  torsion  securing  them  together.  I  have  seldom  met 
with  cases  in  which  this  method  of  treatment  was  necessary. 

The  bones  of  the  nose  are  sometimes  fractured,  although  not  very 


294  LECTURES    ON    PRACTICAL    SURGERY. 

frequently.  When  this  accident  does  occur  the  fracture  can  be  re- 
duced by  the  use  of  a  female  catheter,  a  piece  of  wood,  or  an  ordi- 
nary director.  The  instrument  employed  should  be  passed  into  the 
nostrils,  and  sufficient  force  used  to  raise  the  bone  into  its  place.  In 
one  case  I  treated  in  this  city,  from  which  considerable  deformity 
resulted,  the  nasal  bones  were  not  injured.  The  cartilage  was  de- 
tached from  the  bone  and  forced  backward,  and  in  consequence  of 
the  inflammation  that  followed,  I  was  not  permitted  to  make  an 
effort  to  restore  it  to  its  original  and  natural  position.  After  the 
fracture  has  been  reduced,  cold  applications  should  be  made  to  the 
injured  part,  and  the  same  treatment  observed  as  directed  in  other 
injuries. 

Fractures  of  the  spine  are  always  sooner  or  later  fatal.  The 
water-bed  may  prevent  ulceration  of  the  back  or  bed-sores,  which  al- 
ways occur  in  such  cases  in  consequence  of  the  want  of  vitality. 
Yet  the  paralysis  continues,  and  life  is  really  not  desirable  under 
such  circumstances. 


LECTURE    XXVI.  —  DISLOCATIONS. 


LECTUEE   XXVI. 


GENTLEMEN  :  To-day  I  shall  lecture  on  dislocations  or  luxations, 
by  which  we  mean  the  displacement  of  the  respective  surfaces  of  an 
articulation,  as,  for  example,  when  the  head  of  the  humerus  is  dis- 
lodged from  the  glenoid  cavity. 

These  injuries  may  be:  1st.  Either  partial  or  complete;  2d.  Simple 
or  compound.  Partial  dislocations  seldom  occur,  so  seldom  that  only 
a  few  have  been  recorded.  Sir  Astley  Cooper  mentions  one  which 
he  saw  in  a  shoulder-joint.  In  consequence  of  the  great  size  of  the 
extremities  of  the  bones  which  compose  the  knee-joint,  a  partial 
dislocation  of  that  articulation  occurs  more  frequently  than  else- 
where. The  head  of  the  tibia  may  be  thrown  forwards,  backwards, 
or  to  either  side,  without  the  articulating  surfaces  being  entirely 
separated,  and  the  dislocation  is  then  said  to  be  partial  or  incomplete. 
When,  however,  the  articulating  surfaces  are  entirely  separated,  it  is 
complete. 

A  dislocation  is  simple  when  no  external  wound  exists  communi- 
cating with  it,  as,  for  example,  when  the  head  of  the  humerus  is 
thrown  downwards  into  the  axilla,  even  if  there  is  an  extensive 
laceration  of  the  capsular  ligament.  But  when  the  soft  parts,  by 
which  the  bones  are  covered  and  protected,  are  wounded,  whether 
the  bones  protrude  through  the  wound  or  not,  it  is  called  a  compound 
dislocation,  and  the  difficulty  is  serious  in  proportion  to  the  size  of 
the  joint,  the  extent  of  the  wound,  and  the  violence  of  the  contusion 
by  which  it  is  accompanied. 

Causes. — 1st.  The  most  frequent  cause  is  external  violence.  2d. 
The  second,  inordinate  muscular  action ;  and  the  third,  disease  of  the 
articulation.  Violent  muscular  action  frequently  produces  disloca- 
tion of  the  shoulder-joint.  Some  years  ago  a  young  man  who  was 
suffering  from  epilepsy  came  to  my  office  every  two  or  three  months 
with  a  dislocation  of  one  or  both  humeri,  in  consequence  of  the  arms 
being  thrown  upwards  when  the  paroxysm  commenced.  The  fits 
only  occurred  at  night,  and  the  dislocations  were  prevented  by  secur- 
ing his  arms  to  the  chest  by  a  leather  strap,  which  he  was  directed 


296  LECTURES    ON    PRACTICAL    SURGERY. 

to  apply  every  night  before  he  retired.  The  third  and  last  cause  of 
dislocation  is  disease  of  the  articulating  surfaces,  which  produces 
more  cases  of  dislocation  of  the  hip-joint  than  both  the  preceding. 
When  the  head  of  the  femur  is  destroyed  by  disease  it  escapes  readily 
from  the  acetabulum,  and  rests  upon  the  dorsurn  of  the  ilium;  the 
limb  is  then  permanently  shortened,  and  the  toes  are  turned  inwards. 
Such  cases  are  very  difficult  to  manage  in  this  stage;  unfortunately 
they  are  very  numerous  in  this  city,  in  consequence  of  the  peculiarity 
of  the  climate,  much  more  numerous  than  in  the  Southern  Atlantic 
States  amongst  the  laboring  classes,  and  they  are  usually  neglected 
until  they  become  incurable.  Dislocations  may  be  either  primary  or 
secondary.  When  primary  they  result  from  violence,  and  when 
secondary  from  muscular  action,  as  in  morbus  coxarius,  as  already 
explained.  I  have  a  patient  in  whom  I  have  been  for  several  weeks 
trying  to  prevent  a  dislocation  of  the  hip-joint,  and  now  there  seems 
to  be  a  tendency  to  anchylosis,  which  is  preferable  to  the  shortening 
which  usually  occurs. 

Symptoms. — What  are  the  symptoms  of  dislocation  ?  They  are 
the  reverse  of  those  observed  in  fracture.  1st.  There  is  immobility 
or  fixation,  while  in  fracture  there  is  increased  mobility,  and  you  can 
change  the  position  of  the  part  without  any  difficulty  ;  but  in  disloca- 
tion the  bone  is  fixed,  and  generally  considerable  force  is  required  to 
restore  it  to  its  natural  position.  2d.  Another  symptom  which  gen- 
erally exists  is  shortening,  but  this  does  not  always  occur.  In  dislo- 
cations of  the  shoulder-joint,  unaccompanied  with  fracture,  the  arm 
is  always  elongated,  the  elbow  does  not  occupy  its  usual  position,  it 
being  difficult  to  bring  it  in  contact  with  the  chest.  The  space  be- 
tween the  acrornion  process  and  the  head  of  the  humerus  is  greatly 
increased. 

Deformity  always  exists.  The  amount  depends  upon  the  size  of 
the  articulating  surface  and  the  extent  of  the  displacement.  In 
dislocations,  as  well  as  in  fractures,  you  should  always  expect  swell- 
ing, generally  to  a  degree  proportionate  to  the  amount  of  violence 
offered.  Sometimes  you  will  find  the  part  immensely  swollen,  if 
much  time  has  elapsed  between  the  occurrence  of  the  injury  and  the 
visit  of  the  surgeon.  In  dislocations  the  limb  below  the  seat  of  the 
lesion  is  almost  always  cold.  This  occurs  generally  in  dislocations 
of  the  humerus,  in  consequence  of  the  pressure  made  by  the  head  of 
the  humerus  upon  the  nerves  that  supply  the  arm  and  hand,  as  well 


LECTURE    XXVI.  —  OLD    DISLOCATIONS.  297 

as  of  the  derangement  of  the  circulation  produced  by  the  displace- 
ment of  the  bone. 

There  is  sometimes  numbness,  and  occasionally  an  entire  want  of 
sensibility  in  the  extremity.  The  indication  in  such  cases  is  to 
reduce  the  dislocation,  or  restore  the  articulating  surfaces  to  their 
normal  condition.  This  is  accomplished  by  extension  and  counter- 
extension.  The  extension  is  made  below  the  seat  of  the  injury,  and 
the  counterextension  above,  either  to  the  chest  or  pelvis,  according  to 
the  joint  concerned.  Before  the  discovery  of  chloroform  it  was 
sometimes  exceedingly  difficult  to  reduce  a  dislocation,  in  consequence 
of  the  resistance  offered  by  the  muscles  implicated.  I  always  used 
the  lancet.  The  patient  was  required  to  remain  seated,  a  vein  was 
opened,  and  the  blood  allowed  to  flow  until  syncope  was  threatened, 
which  is  always  accompanied  by  so  much  muscular  relaxation  that 
no  obstacle  is  presented,  and  the  reduction  becomes  easy. 

Some  years  ago,  it  was  supposed  that  the  shoulder-joint  could  not 
be  reduced  after  it  had  been  dislocated  more  than  three  months.  In 
1854,  when  I  had  charge  of  the  United  States  Marine  Hospital,  in 
this  city,  the  first  officer  of  a  Boston  clipper  was  admitted,  with  a  dis- 
location of  the  shoulder,  which  had  existed  three  months  and  seven- 
teen days.  Malgaigne's  method  was  adopted,  and  the  restoration 
of  the  bone  accomplished.  When  I  was  a  student  in  Paris,  there 
was  a  woman  in  Dupuytren's  ward,  in  the  Hotel  Dieu,  who  had  a 
dislocation  of  the  shoulder.  Dupuytren  failed  to  reduce  it  by  the 
ordinary  method  employed  in  such  cases,  and  Malgaigne  obtained 
Dupuytren's  consent  to  deliver  a  lecture  to  the  class  and  attempt 
the  reduction  by  a  new  method  which  he  had  found  successful. 

This  consisted  in  securing  the  body  by  strong  bandages,  and  when 
the  extending  apparatus  was  adjusted,  the  arm  was  brought  gradu- 
ally round  until  it  was  on  a  line  with  the  body.  The  head  of  the 
bone  was,  by  this  procedure,  removed  from  the  axilla,  and  then  the 
assistants  were  directed  to  continue  the  force  applied,  and  gradually 
restore  the  bone  to  its  natural  position.  Malgaigne  held  the  humerus 
just  below  the  head,  but  being  feeble,  the  effort  failed.  It  was,  how- 
ever, soon  repeated,  and  Dupuytren,  with  his  strength  and  skill, 
guided  by  the  genius  and  enthusiasm  of  Malgaigne,  succeeded  per- 
fectly. 

Two  years  since,  a  man  was  admitted  into  the  County  Hospital, 
with  a  dislocation  of  the  shoulder-joint,  which  occurred  four  months 


298  LECTURES    ON    PRACTICAL    SURGERY. 

and  a  half  before,  in  a  neighboring  town.  The  college  was  in  ses- 
sion, and,  by  adopting  Malgaigne's  method,  the  dislocation  was  re- 
duced at  the  second  attempt,  and  the  arm  became,  after  a  few  weeks, 
as  useful  as  before. 

Sometimes  a  dislocated  shoulder  can  be  reduced  by  taking  hold  of 
the  hand,  and  with  the  foot  placed  in  the  axilla  and  the  attention  of 
the  patient  diverted  so  as  not  to  make  any  resistance,  more  easily 
than  by  any  other  method,  and  without  any  assistance. 

After  the  reduction  of  a  dislocated  shoulder,  cotton  should  be 
placed  in  the  axilla,  the  hand  supported  by  a  sling  and  the  arm  con- 
fined to  the  body  for  a  week;  then  it  should  be  released  during  the 
day  and  confined  at  night  for  a  week  or  two  longer. 

The  joint  should  be  moved  half  a  dozen  times  a  day  so  as  to  re- 
store the  function  as  speedily  as  possible,  otherwise  anchylosis  might 
occur,  which  would  destroy  the  value  of  the  reduction.  Although 
in  dislocations  of  the  shoulder-joint  the  head  of  the  bone  is  thrown 
inward,  downward,  or  outward,  and  the  cavity  is  empty  and  nothing 
can  be  felt  except  the  stretched  fibres  of  the  deltoid  muscles,  yet 
many  physicians  mistake  a  dislocation  of  the  shoulder-joint  for  a 
contusion,  and  treat  it  accordingly  until  the  reduction  is  difficult  and 
sometimes  impossible. 

Such  a  mistake  I  regard  as  inexcusable.  The  symptoms  are  so 
decided  that  any  man  who  has  intellect  enough  to  make  a  re- 
spectable physician  should  be  able  by  a  glance  to  detect  the 
difficulty. 

Occasionally  in  cases  of  dislocation  of  the  humerus  of  long 
standing  the  axillary  artery  is  lacerated  by  the  force  required  to 
restore  the  bone  to  its  natural  position ;  and  the  fact  of  this  risk 
should  be  communicated  to  the  patient  before  the  effort  is  made, 
for  self-protection. 

Dislocation  of  the  elbow-joint  occasionally  occurs,  and  is  some- 
times, even  by  physicians,  mistaken  for  fracture.  When  the  elbow- 
joint  is  dislocated,  the  olecranon  process  of  the  ulna  is  thrown 
backward  and  upward,  the  forearm  is  fixed  or  almost  immovable, 
the  arm  is  shortened,  and  the  function  of  the  joint  is  destroyed. 
This  displacement  is  easily  recognized  and  can  be  speedily  replaced. 
To  recapitulate,  in  dislocation  of  the  elbow-joint  the  olecranon  is 
very  prominent.  The  arm  cannot  be  flexed  without  great  pain;  it 
is  diminished  in  length  and  can  be  reduced  more  easily  than  any 


LECTURE    XXVI.  —  DISLOCATIONS.  299 

other  dislocation  of  an  important  joint,  unless  it  has  been  ne- 
glected, and  then  after  the  expiration  of  six  weeks  it  is  regarded  by 
Professor  Gross,  who  is  the  highest  authority,  and  others  as  im- 
possible. An  assistant  is  seldom  necessary  to  enable  you  to  reduce 
a  dislocation  of  the  elbow-joint.  If  you  have  an  assistant,  he 
should  take  hold  of  the  arm  and  hold  it  firmly,  until  the  extending 
force  is  sufficient  to  reduce  the  dislocation.  Occasionally  in  dis- 
locations of  the  elbow-joint,  if  the  coronoid  process  is  fractured  it 
becomes  difficult  and  sometimes  impossible  to  prevent  a  recurrence 
of  the  displacement.  Three  or  four  years  since  I  treated  a  patient  from 
Sonoma  County,  who  had  a  dislocation  of  the  elbow-joint  with  a 
fracture  of  the  coronoid  process  of  the  ulna.  I  reduced  the  dislo- 
cation, but  was  unable  to  prevent  its  recurrence  by  the  ordinary 
treatment,  and  was  finally  compelled  to  secure  the  forearm  to  the 
arm  with  a  bandage,  and  keep  it  thus  bound  until  the  ligament 
united  and  became  sufficiently  strong  to  overcome  that  tendency. 

A  simple  dislocation  of  the  elbow-joint  seldom  gives  rise  to 
serious  consequences.  Sometimes,  however,  and  particularly  when  a 
strumous  diathesis  exists,  inflammation  may  follow  either  a  dis- 
location or  contusion,  and  then  great  difficulty  will  be  experienced 
to  prevent  anchylosis.  The  forearm  should  be  flexed  and  extended 
every  two  or  three  days,  and  if  anchylosis  must  occur,  the  forearm 
should  be  bent  so  as  to  form  an  angle  with  the  arm,  and  retained  in 
that  position  until  the  motion  is  destroyed.  Dupuytren  believed 
that  the  wrist-joint  was  never  dislocated  without  a  fracture  of  the 
radius,  and  for  many  years  I  entertained  the  same  opinion,  until  I 
met  with  a  case  of  dislocation  of  the  wrist  without  a  fracture.  Re- 
duce the  dislocation,  apply  a  pistol-splint  and  keep  it  on  until  the 
ligaments  unite,  otherwise  you  will  have  as  much  deformity  as 
would  result  from  an  improper  treatment  of  a  fracture  of  the  radius, 
complicated  with  a  dislocation  of  the  lower  extremity  of  the  ulna. 

The  most  difficult  dislocation  of  the  superior  extremity  to  reduce 
is  that  of  the  metacarpal  bone  of  the  thumb.  I  have  treated  two 
cases  in  this  city,  and  succeeded  in  reducing  both.  The  first  had  re- 
sisted the  efforts  of  the  best  physicians  in  the  city  for  several  days. 
I  gave  chloroform,  the  end  of  the  thumb  was  secured  by  a  clove- 
hitch,  and  by  extension  and  counterextension  the  joint  was  reduced 
without  dividing  the  flexor  muscles  of  the  thumb,  as  recommended 
and  practiced  by  our  ablest  surgeons. 


300  LECTURES    ON    PRACTICAL    SURGERY. 

The  fingers  may  be  dislocated  in  any  direction,  and  are  easily  re- 
duced, and  should  be  kept  for  a  few  days  immovable  by  the  ap- 
plication of  splints  composed  of  blotting-paper  or  pasteboard.  The 
more  simple  the  dressing  the  better;  the  bandages  should  not  be 
sufficiently  tight  to  produce  pain,  and  then  you  will  not  have  any 
difficulty  after  the  dislocation  is  reduced. 

The  condyles  or  articulating  surfaces  of  the  inferior  maxillary 
bone  are  often  dislocated.  The  patient  is  then  unable  to  close  his 
mouth.  A  negro  man  came  to  my  office  some  months  since  for  the 
first  time,  with  his  mouth  open  and  unable  to  speak.  I  found  upon 
making  an  examination  that  both  of  the  condyles  were  thrown  in 
front  of  the  zygomatic  processes. 

It  is,  although  a  very  distressing  accident,  a  very  simple  one,  and  re- 
duction is  generally  easy.  The  thumbs  being  protected  by  a  towel  or 
handkerchief  should  be  placed  upon  the  posterior  molar  teeth,  and 
while  they  are  pressed  downward  and  backward  the  chin  should  be 
elevated  with  the  fingers  of  both  hands,  by  which  manoeuvre  the  bone 
will  generally  slip  back  into  its  place.  Sometimes,  however,  after 
this  accident  has  once  happened,  it  is  very  liable  to  recur,  in  con- 
sequence of  relaxation  of  the  ligaments,  and  then  it  becomes  neces- 
sary for  the  patient  to  have  the  lower  jaw  secured  at  night  by  a 
bandage,  to  prevent  the  mouth  from  being  widely  opened. 

Dislocations  of  the  clavicle,  although  not  very  frequent,  occasion- 
ally occur.  Since  the  commencement  of  this  course  of  lectures  you 
have  seen  a  case  of  dislocation  of  the  acromial  end  of  the  clavicle  ; 
the  ligaments  yielded  and  the  extremity  of  the  bone  was  displaced. 
Dislocations  of  this  bone  are  much  more  common  than  I  at  one  time 
supposed.  When  sufficient  force  is  applied  to  the  shoulder  the 
clavicle  generally  breaks  about  the  external  third,  but  when  the 
bone  is  stronger  than  the  ligament,  instead  of  a  fracture  we  find  a 
dislocation. 

After  reducing  a  dislocation  of  either  the  sternal  or  acromial  end 
of  the  clavicle,  you  will  find  that  your  troubles  have  only  com- 
menced. I  have  after  many  years  of  experience,  and  after  being 
disappointed  by  the  bandages  recommended,  discarded  them  en- 
tirely, and  now  rely  upon  a  compress  and  adhesive  plaster.  And, 
gentlemen,  I  can  say  that  the  only  cases  I  have  ever  treated  suc- 
cessfully and  satisfactorily,  both  to  myself  and  the  patient,  were  treated 
by  this  method.  A  compress  of  lint  should  be  applied ;  the 


LECTURE    XXVI.  —  DISLOCATIONS.  301 

shoulders  are  then  to  be  drawn  back  by  an  assistant,  and  strips  of 
adhesive  plaster  half  an  inch  wide  applied  as  firmly  as  possible. 
They  should  extend  eight  or  ten  inches  below  the  clavicle  on  each 
side,  and  be  allowed  to  remain  as  long  as  they  adhere  closely  and 
firmly  to  the  skin.  The  arm  should  be  supported  by  a  sling.  And 
I  now  do  not  feel  any  uneasiness  in  reference  to  the  result  of  a  dis- 
location of  the  clavicle  treated  by  this  method. 


302  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   XXVII. 

I  WILL  direct  your  attention  this  morning  to  dislocations  of  the 
hip-joint,  a  lesion  which  occasionally  occurs,  and  which  is  always 
serious.  Although  I  have  practiced  more  than  thirty  years,  I  have 
only  treated  two  cases  of  this  character.  One  occurred  in  South 
Carolina  and  the  other  in  California.  The  former  was  a  female 
servant,  about  twenty-five  years  old.  She  fell  from  a  hay  wagon, 
about  five  yards,  struck  upon  her  feet,  and  dislocated  the  left  hip- 
joint.  The  head  of  the  femur  was  thrown  upward  and  outward, 
resting  upon  the  dorsum  of  the  ilium,  and  the  limb  was  shortened 
about  three  inches.  In  the  case  which  occurred  in  California,  the 
limb  was  elongated  in  consequence  of  the  dislocation  being  down- 
ward, which  resulted  from  a  fall  upon  the  side  on  shipboard. 

This  joint  may  be  dislocated  in  four  directions.  The  first  and 
most  frequent  is  upward  and  backward,  upon  the  dorsum  of  the 
ilium,  the  force  being  applied  to  the  feet  when  the  extremities  are 
extended.  The  round  ligament  is  lacerated,  and  the  head  of  the 
bone  occupies  the  position  before  indicated.  The  toes,  in  this  dislo- 
cation, always  turn  inward.  There  exists  considerable  immobility, 
and  the  amount  of  shortening  already  specified.  In  fracture  of  the 
neck  of  the  thigh-bone  there  is  perfect  mobility,  the  foot  always  turns 
outward,  unless  the  head  of  the  bone  is  forced  up  under  the  glutei 
muscles.  A  case  of  this  character  was  given  when  fractures  were 
under  consideration. 

2d.  In  the  second  form  of  dislocation  of  the  hip-joint,  the  head 
of  the  femur  is  thrown  backward  into  the  sacro-ischiatic  notch,  the 
extremity  is  not  much  shortened,  and  the  position  of  the  toes  but 
little  changed. 

3d.  The  head  of  the  femur  is  thrown  downward  into  the  foramen 
ovale;  then  the  limb  is  elongated,  probably  more  than  an  inch,  and 
the  toes  are  turned  inward,  and  remain  fixed  in  that  position.  I 
met  with  a  case  of  this  character,  in  the  San  Francisco  County  Hos- 
pital, which  has  already  been  mentioned. 


LECTURE    XXVII.  —  DISLOCATIONS.  303 

4th.  The  head  of  the  femur  may  be  forced  upward  upon  the  pubis, 
when  there  will  be  but  little,  if  any,  shortening,  and  the  toes  turn 
outward. 

To  recapitulate,  in  the  first,  which  is  the  most  common,  the  head 
of  the  bone  is  thrown  upward  and  backward.  2d.  Backward  and 
downward  into  the  sacro-ischiatic  notch,  accompanied  with  very  little 
shortening  or  change  of  position.  3d.  Downward  and  forward  into 
the  foramen  ovale,  with  elongation  and  inversion  of  the  toes.  4th. 
Forward  upon  the  pubis,  with  e version  of  the  toes,  with  an  inability 
to  move  the  limbs. 

The  indication,  in  every  variety  of  dislocation  of  the  hip-joint,  is 
to  restore  the  head  of  the  bone  to  its  natural  position,  and  this  can 
be  accomplished  only  by  making  extension  and  counterextension, 
and,  at  the  same  time,  adopting  such  means  as  are  calculated  to  facil- 
itate the  passage  of  the  head  of  the  bone  from  its  unnatural  position 
into  the  acetabulum.  Before  the  discovery  of  anaesthetics,  and  when 
the  physician  was  too  timid  to  bleed,  so  as  to  produce  muscular  re- 
laxation, pulleys  were  often  employed,  and  sometimes  successfully, 
but  often  the  result  was  not  satisfactory. 

Twenty- five  years  ago  I  was  called  to  see  a  strong  colored  man 
who  had  a  dislocation  of  the  shoulder.  The  physician  of  the  family 
being  sent  for,  he  fixed  the  body  of  the  man  to  a  large  oak  tree  in 
the  yard  by  a  sheet.  Bandages  were  applied  to  the  forearm,  and  five 
strong  men  were  directed  to  use  all  the  power  they  could  command; 
yet  every  effort  was  ineffectual.  Late  in  the  afternoon  I  was  re- 
quested to  see  the  patient,  who  lived  five  miles  from  the  city.  I 
found  him  fastened  to  the  tree,  complaining  of  great  soreness  of  the 
shoulder,  and  very  much  exhausted  by  the  repeated  but  unsuccess- 
ful efforts  made  by  brute  force  to  reduce  the  arm.  I  removed  the 
bandages  from  the  arm  and  opened  a  vein.  The  blood  flowed  in 
a  free  stream,  and  very  soon  syncope  was  threatened.  The  flow 
of  blood  was  then  arrested ;  I  took  hold  of  the  arm,  a  strong  man 
grasped  the  wrist,  and,  with  my  assistance,  the  head  of  the  bone 
slipped  into  the  socket,  to  the  astonishment  of  every  person  present, 
and  to  the  discomfiture  of  the  physician.  When  a  patient  is  under 
the  influence  of  chloroform  but  little  force  is  needed,  consequently 
the  accidents  resulting  from  efforts  to  reduce  dislocations  occur  much 
less  frequently  than  formerly.  With  moderate  extension  and  counter- 


304  LECTURES    ON    PRACTICAL    SURGERY. 

extension,  and  the  proper  direction  of  the  head  of  the  bone,  any 
dislocation  can  be  reduced  without  much  difficulty. 

Knee-joint. — Dislocations  of  the  knee-joint,  in  consequence  of  the 
great  extent  of  the  articulating  surfaces,  are  very  uncommon,  but 
when  they  do  occur  they  are  always  serious,  and,  if  compound,  ex- 
ceedingly dangerous.  I  have  practiced  a  long  time,  and  have  only 
met  with  one  case  of  dislocation  of  the  knee-joint.  It  was  produced 
by  the  patient  falling  down  a  flight  of  stairs.  The  subject  was  a 
female  about  forty  years  old.  The  dislocation  was  posterior  and 
complete,  and  was  reduced  very  easily  by  the  assistance  of  the  hus- 
band. A  splint  was  applied  for  the  purpose  of  preventing  a  recur- 
rence of  the  lesion.  It  was  removed  after  seven  days,  and  reapplied 
after  flexing  and  extending  the  limb,  which  is  considered  very  im- 
portant in  all  cases  of  this  character.  During  the  time  I  was  in  the 
hospitals  of  Paris  not  a  single  case  of  this  character  was  admitted. 
This  dislocation  may  occur,  and  present  four  varieties.  In  the  first 
the  condyles  of  the  femur  are  thrown  forward.  In  the  second  back- 
ward, and  the  tibia  becomes  very  prominent.  In  the  third  and  fourth 
varieties  the  dislocation  is  lateral.  I  think  partial  dislocations  of 
the  knee-joint  are  much  more  common  and  much  less  dangerous. 

In  consequence  of  the  size  of  the  bones  which  compose  the  knee- 
joint,  and  the  slight  protection  afforded  by  the  surrounding  parts, 
compound  luxations  are  much  more  dangerous  than  simple.  Even 
if  considerable  swelling  exists,  this  dislocation  is  seldom  mistaken 
for  any  other  accident,  even  by  the  most  inexperienced  practitioners. 
The  joint  is  immovable,  unless  by  considerable  effort,  there  is  always 
pain,  and  when  the  dislocation  is  complete  there  is  both  shortening 
and  marked  deformity,  which  cannot  be  mistaken.  The  ligaments, 
in  such  cases,  are  all  lacerated,  and  after  the  administration  of  chlo- 
roform but  little  difficulty  will  be  experienced  in  restoring  the  rela- 
tion of  the  bones.  Inflammation  may  follow  in  a  simple  case,  but 
in  the  compound  it  is  very  seldom  that  the  leg  is  saved,  and  when  it 
is  anchylosis  almost  always  results.  Except  under  the  most  favor- 
able circumstances,  amputation  should  be  recommended,  and  the 
time  that  should  be  allowed  to  elapse  after  the  injury  must  depend 
on  the  condition  of  the  patient. 

Dislocations  of  the  ankle  may  occur  in  four  directions, — inward, 
outward,  backward,  and  forward.  With  the  position  of  the  bones  of 
the  leg  and  the  astragalus  you  are  all  familiar.  The  tibia  rests  upon 


LECTURE    XXVII.  —  DISLOCATION    OF    ASTRAGALUS.        305 

the  astragalus  above,  and  protects  it  on  the  inner  side,  and  the  fibula 
performs  the  same  office  externally.  In  lateral  dislocations  of  the 
ankle-joint  there  is  always  a  fracture  either  of  the  tibia  or  fibula, 
and  the  fracture  and  the  dislocation  may  be  either  simple  or  com- 
pound. To  illustrate,  I  will  describe  a  very  remarkable  case  which 
occurred  in  this  city.  It  was  remarkable  both  for  the  extent  of  the 
injury  as  well  as  the  result.  One  of  our  most  distinguished  United 
States  Senators  was  thrown  from  a  buggy  and  severely  injured.  The 
tibia  of  the  right  leg  was  fractured  near  the  ankle,  the  fibula  was 
dislocated  and  protruded  through  a  wound  more  than  three  inches 
long.  The  foot  was  turned  inward,  and  fixed  by  the  position  of  the 
fibula.  When  I  arrived  I  found  other  physicians  present,  and,  when 
the  boot  was  removed,  they  thought  that  amputation  should  be  per- 
formed at  once,  as  they  believed  that  it  afforded  the  only  chance  for 
life.  The  dislocated  and  fractured  bones  were  reduced,  the  limb  was 
placed  on  a  double  inclined  plane,  morphia  was  administered  to  re- 
lieve pain,  irrigation  was  continued  for  ten  days,  until  the  danger 
from  inflammation  had  passed,  and  then  the  warm-water  dressing 
was  applied,  and  continued  until  the  wound  healed.  He  left  his 
room  well,  with  perfect  motion  of  the  joint,  in  forty-two  days  after 
the  occurrence  of  the  accident,  to  attend  to  some  business  in  Sacra- 
mento City,  in  this  State.  The  ankle-joint  may  be  dislocated  either 
forward  or  backward  without  a  fracture  of  either  of  the  bones  of  the 
leg.  ]N"o  difficulty  is  generally  experienced  in  reducing  a  dislocation 
of  the  ankle-joint. 

The  astragalus  may  be  dislocated  as  well  as  the  bones  of  the  leg, 
which,  with  it,  form  the  ankle-joint.  Some  years  since,  a  stage  con- 
tractor, named  McClain,  jumped  from  the  driver's  seat  of  a  stage 
when  the  horses  were  running  at  full  speed.  He  sustained  a  com- 
pound dislocation,  and  the  astragalus  protruded  through  the  external 
wound.  This  accident  occurred  more  than  twenty-five  years  ago,, 
and,  consequently,  I  could  not  refer  to  any  author  for  guidance  as 
to  the  treatment  in  such  cases.  We  had  a  consultation,  and  I  was 
in  the  minority. 

All  the  physicians  present  thought  that  amputation  was  indispen- 
sable. McClain  consented,  provided  I  thought  it  necessary.  I  re- 
moved the  astragalus,  closed  the  wound  partially,  applied  cold  water, 
with  a  splint  well  padded  on  the  inside  of  the  limb.  The  extremity 
was  saved  ;  it  was  about  an  inch  shorter  than  the  other  leg  ;  there  was 

20 


306  LECTURES    ON    PRACTICAL    SURGERY. 

considerable  motion  in  the  joint.  It  was  one  of  my  triumphs  and 
was  called  Toland's  luck  in  surgery.  Should  the  astragalus  be  dis- 
located without  an  external  wound,  and  reduction  be  found  to  be 
impossible,  an  incision  should  be  made,  the  bone  removed  and  the 
case  treated  as  already  indicated.  Never  allow  a  patient,  either  after 
a  surgical  operation  or  an  injury,  to  suffer  pain.  Ubi  irritatio  ibi 
flaxus  is  unquestionably  true,  and  the  surgeon  who  ignores  the 
adage  never  will  be  successful. 

The  metatarsal  bones  are  seldom  dislocated  without  being  frac- 
tured also;  the  injury  is  generally  produced  by  a  heavy  weight 
falling  upon  the  foot.  A  man  has  recently  been  admitted  into  the 
surgical  ward  of  the  hospital  with  a  dislocation  of  the  metatarsal 
bones,  without  a  fracture,  but  such  cases  are  exceedingly  rare,  and 
when  they  do  occur,  it  is  only  necessary  to  place  the  bones  in  their 
normal  position  and  apply  a  well-padded  splint  to  the  sole  of  the 
foot,  and  keep  it  on  until  the  ligaments  have  become  sufficiently 
strong  to  retain  the  bones  in  their  natural  position. 

The  toes  are  frequently  dislocated,  but  very  little  difficulty  is  ex- 
perienced in  reducing  them,  except  it  be  in  the  case  of  the  first  joint 
of  the  great  toe.  I  found  a  case  of  that  character  in  the  County 
Hospital  in  1853.  The  patient  was  a  strong  young  Englishman,  who 
had  fallen  through  a  scuttle,  and  had  dislocated  the  first  joint  of 
the  great  toe.  Jarvis's  adjuster  was  applied  and  the  bone  was  re- 
placed in  a  few  minutes.  This  dislocation  is  about  as  difficult  to 
reduce  as  a  dislocation  of  the  second  joint  of  the  thumb.  You 
might  suppose  that  it  would  be  very  easy  to  pull  either  the  thumb 
or  toe  off  entirely,  but  after  you  have  treated  two  such  cases  as 
those  I  have  described  you  will  arrive  at  a  different  conclusion. 
The  flexor  muscles  of  the  thumb  and  great  toe  are  so  strong  that 
without  the  influence  of  an  anaesthetic  the  reduction  would  be  very 
difficult,  if  not  impossible. 

False  Joints. — Having  omitted  the  consideration  of  this  subject  in 
my  lecture  on  fractures,  I  beg  leave  now  to  refer  to  it.  It  is  very 
important;  so  important  that  every  practitioner  should  be  familiar 
with  the  best  method  of  treating  it  in  every  variety,  or,  in  other 
words,  in  every  location. 

A  false  joint  may  occur  in  a  long  bone  at  any  point  between  the 
articulating  surfaces,  and  when  in  the  centre  an  operation  is  less 
difficult  than  near  the  extremities. 


LECTURE    XXVII.  —  FALSE    JOINT.  307 

After  a  fracture,  sometimes  bony  union  fails  to  take  place;  the 
ends  are  covered  by  a  fibrous  or  ligamentous  tissue  which  extends 
from  one  extremity  to  the  other,  and  does  not  become  ossified.  In 
other  cases  the  connection  resembles  the  ball  and  socket-joint,  and 
without  proper  treatment  it  cannot  be  cured. 

Treatment. — Three  methods  have  been  adopted  for  the  purpose  of 
effecting  union  when  a  false  joint  does  really  exist.  Dr.  Physick 
recommended  that  the  extremities  should  be  rubbed  forcibly  to- 
gether; that  irritants  should  be  applied,  and  the  patient  allowed  to 
take  active  exercise;  should  this  fail  he  recommended  that  a  seton 
be  passed  between  the  ends  of  the  bone  and  allowed  to  remain 
until  a  considerable  degree  of  inflammation  is  produced.,  when  the 
seton  should  be  removed  and  the  case  treated  like  one  of  recent 
fracture.  Professor  Brainard,  in  order  to  fulfil  the  same  indication, 
passed  ivory  pins  between  the  ends  of  the  bones,  and  allowed  them 
to  remain  until  the  desired  effect  was  obtained.  He  thought  they 
were  superior  to  the  seton,  because  the  external  wound  which  re- 
sulted was  less  extensive,  and  consequently  healed  more  readily. 
When  friction,  the  seton,  or  ivory  pins  all  fail,  the  only  alternative 
left  is  to  resect,  or  in  other  words  remove  with  a  chain-saw  the  ex- 
tremities of  the  fractured  bone,  drill  a  hole  in  each,  pass  a  strong 
silver  wire  through  the  opening,  bring  the  extremities  together, 
make  three  turns  to  the  right,  and  then  make  a  memorandum  and 
keep  it  so  that  you  may  not  have  any  trouble  in  removing  the  wire 
when  its  presence  should  be  ^dispensed  with.  In  the  first  operation 
of  this  kind  which  I  performed,  I  experienced  more  difficulty  in  re- 
moving than  in  inserting  the  wire,  but  if  this  precaution  be  taken 
it  obviates  the  only  difficulty  in  such  cases.  It  is  not  difficult  to 
perform  these  operations,  but  you  should  always  weigh  carefully  the 
probabilities  as  to  the  result.  I  have  resected  the  thigh-bone  three 
times ;  two  recovered,  and  the  third  died  in  the  County  Hospital  seven 
days  after  the  operation,  in  a  typhoid  state  which  was  produced 
either  from  the  dread  of,  or  the  shock  resulting  from,  the  operation. 
I  have  resected  the  arm,  the  forearm,  and  the  leg  successfully,  and 
although  I  have  only  lost  one  case  from  an  operation  of  this  character 
upon  the  thigh,  I  regard  it  as  one  of  very  serious  importance,  and 
one  which  should  not  be  performed  until  every  other  treatment  has 
failed.  I  have  never  resected  the  bones  of  the  leg  in  ununited 
fracture  but  once.  In  that  case  the  bones  overrode  one  another  at 


308  LECTURES    ON    PRACTICAL    SURGERY. 

least  two  inches,  and  from  the  length  of  time  that  had  elapsed  I 
was  convinced  that  the  operation  afforded  the  only  chance  for  relief. 
The  gentleman  was  from  Placerville,  and  the  operation  was  performed 
at  St.  Mary's  Hospital,  in  this  city.  A  case  of  ununited  fracture 
has  never  occurred  in  my  practice ;  in  every  case  of  the  kind  in  the 
leg  which  I  have  treated,  if  the  ends  of  the  bone  touch,  I  have 
never  failed  to  effect  a  solid  union,  and  I  am  happy  to  say  that  by 
my  advice  and  attention  I  have  saved  several  of  my  confreres  from 
suits  for  malpractice.  Should  a  fractured  arm,  forearm,  or  leg  fail 
to  unite  in  six  weeks,  a  starch  bandage  should  be  applied  with  one 
splint  for  support,  and  the  patient  directed  to  exercise  the  limb  as 
much  as  possible.  Should  it  become  very  painful,  rest  should  be 
enjoined  until  the  inflammation  partially  subsides,  and  then  the  ex- 
ercise should  be  resumed.  The  members  of  this  and  every  other 
class  who  have  followed  me  in  the  County  Hospital,  can  substantiate 
the  truth  of  the  statement  I  have  made. 

In  resections  of  the  thigh-bone  the  incisions,  if  possible,  should  be 
made  upon  the  outside  of  the  limb,  so  as  not  only  to  avoid  the 
vessels  and  nerves,  but  also  to  provide  for  drainage ;  which,  I  think, 
in  treating  all  wounds,  is  of  more  importance  than  everything  else 
connected  with  such  cases.  If  the  incision  be  made  upon  the  ex- 
ternal side  of  the  limb,  the  wound  will  find  ready  drainage.  In  a 
patient  with  a  good  constitution  and  unimpaired  general  health  the 
operation  is  justifiable,  yet  the  physician  should  never  persuade  a 
patient  by  misrepresentation  to  submit  to  this  or  any  other  operation, 
except  under  the  circumstances  already  specified. 


LIB.KAIt 

UN  IT  EH  SIT' Y  O* 

CALIF          'A. 


LECTURE    XXVIII.  —  DISEASES    OF    BONES.  309 


LECTURE   XXVIII. 

GENTLEMEN  :  In  this  lecture  I  will  endeavor  to  describe  the  dis- 
eases of  the  bones.  A  bone  in  its  natural  and  healthy  condition  is 
almost  entirely  devoid  of  sensibility.  But  when  either  the  bone  or 
its  covering,  the  periosteum,  becomes  inflamed,  the  pain  is  exceed- 
ingly acute,  greater  than  that  experienced  in  any  other  disease,  ex- 
cept inflammation  of  the  ear,  the  parotid  gland,  the  frontal  sinus, 
and  the  nerves  of  the  teeth. 

The  inflammation  may  be  confined  to  the  periosteum,  or  may 
extend  to  the  bone,  and  then  both  tissues  are  implicated  at  the  same 
time.  In  a  healthy  bone  the  vessels  are  not  visible,  but  when  in- 
flamed they  become  distended  with  blood,  as  do  also  many  which 
were  impervious  before  the  bone  became  inflamed.  This  inflamma- 
tion is  more  intense  in  spots,  which  produces  irregularity  in  the  red- 
ness of  the  part.  In  some  cases  the  entire  periosteum  of  one  or 
more  of  the  phalanges  of  the  fingers  becomes  implicated,  and  if  not 
properly  treated  is  detached  and  separated  from  the  bone,  which  loses 
its  vitality,  becomes  an  extraneous  body,  and  if  removed  when  the 
separation  of  the  periosteum  is  complete  another  bone  or  bones  will 
form,  with  the  intervening  joints,  which  will  be  as  useful  as  the  orig- 
inal. And  for  more  than  twenty  years  a  knowledge  of  the  repro- 
duction of  bones,  joints,  and  ligaments  has  saved  more  limbs  and 
prevented  more  cases  of  deformity  than  any  discovery  that  has  been 
made  during  the  last  quarter  of  a  century.  Professor  Benjamin 
Dudley,  my  old  teacher,  was  aware  of  the  reproduction  of  the  first 
joint  of  the  thumb  and  fingers,  but  I  first  demonstrated,  in  San 
Francisco,  that  entire  fingers  and  joints  can  be  reproduced  and  be- 
come as  useful  as  before  they  were  diseased.  These  are  not  the  only 
bones  that  are  reproduced,  as  will  appear  before  the  consideration  of 
this  subject  is  completed. 

When  the  periosteum  is  inflamed  to  a  limited  extent,  pus  forms 
between  that  membrane  and  the  bone,  the  membrane  is  detached,  the 
pus  escapes  by  ulceration,  and  the  external  surface  of  the  bone  being 


310 


LECTURES  ON  PRACTICAL  SURGERY. 


deprived  of  vitality  exfoliates,  or,  in  other  words,  is  detached  from 
the  healthy  bone,  and  escapes  or  is  removed  through  the  opening 
produced  by  the  escape  of  the  purulent  matter.  When  the  entire 
periosteum  of  a  bone  is  inflamed,  as  already  stated,  the  formation  of 
matter  separates  it  from  the  bone,  which  is  called  necrosis,  and  if  a 


FIG.  67. 


new  bone  is  formed  over  the  necrosed  bone,  the  latter  is  called  a 
sequestrum.  Many  limbs  have  been  removed  because  portions  of 
necrosed  bones  were  included  in  the  cavity  of  one  newly  formed  by 
the  detached  periosteum,  because  it  was  generally  supposed  that  when 
a  bone  is  diseased  it  cannot  again  become  healthy.  Frequently  the 


LECTURE    XXVIII.  —  REPRODUCTION    OF    BONES. 


311 


new  bone  forms  upon  one  side  of  the  original  bone,  and  is  entirely 
separated  from  it,  and  can  be  removed  without  interfering  at  all 
with  that  which  has  been  reproduced.  I  operated  upon  a  case  of 
this  character  a  few  years  since,  which  occurred  in  the  southern  part 
of  the  State,  with  entire  success,  as  well  as  upon  the  tibia  of  a  young 
man  from  Oregon  which  presented  the  same  peculiarity.  This  oper- 


FlG. 


ation  was  performed  before  the  class  in  1863,  and  he  visited  the 
amphitheatre  daily  until  he  was  entirely  well.  In  1853  I  ampu- 
tated the  arm  of  a  miner  at  the  shoulder-joint,  in  a  case  of  that- 
character,  in  the  City  and  County  Hospital,  and  I  now7  will  only  say 
that  if  I  had  that  case  to  treat  again,  although  the  entire  bone  was- 
diseased,  I  would  not  amputate,  but  would  remove  all  the  dead  bone 
and  probably  save  the  arm. 

When  a  sequestrum  cannot  be  removed  from  the  opening  formed 
for  the  purpose  of  allowing  the  purulent  secretion  to  escape,  the 
orifice  should  be  enlarged  either  with  a  trephine  or  chisel.  It  should 


312          LECTURES  ON  PRACTICAL  SURGERY. 

be  large  enough  to  admit  the  introduction  of  dressing  forceps,  which 
are  more  convenient  than  even  toothed  forceps  for  that  purpose.  I 
operated,  some  years  since,  upon  a  boy,  who  lived  on  Fulton  Street, 
in  Hays  Valley,  who  injured  his  ankle  by  jumping  from  a  street  car 
when  in  motion.  The  ankle-joint  inflamed,  was  excessively  painful, 
the  periosteum  was  detached,  and  the  articulating  surfaces  were  dis- 
eased. His  physician  called  a  consultation,  and  they  decided  that 
the  foot  could  not  be  saved  and  that  amputation  of  the  limb  was 
necessary.  Dr.  Sawyer  was  one  of  the  consulting  physicians.  His 
mother  objected,  sent  for  me  the  next  morning,  and  in  a  few  days  I 
removed  three  inches  of  the  lower  extremity  of  the  tibia,  the  ex- 
tremity of  the  fibula,  and  the  astragalus,  with  the  trephine,  the  gouge, 
chisel,  and  toothed  forceps.  In  a  month  new  bone  had  formed,  he 
began  to  take  exercise,  and  now  his  leg,  ankle,  and  foot  are  healthy, 
and  the  only  inconvenience  he  experiences  is  from  anchylosis  of 
the  joint.  He  is  an  engineer  by  profession,  and  finds  very  little 
inconvenience  from  an  injury  which  one  of  our  most  prominent  sur- 
geons thought  sufficiently  serious  to  require  amputation. 

We  will  now  consider  how  these  cases  should  be  treated.  Inflam- 
mation almost  always  commences  in  the  periosteum ;  the  pain  is  acute, 
and  whether  the  bone  be  small  or  large  an  incision  should  be  made 
sufficiently  deep  to  divide  the  periosteum,  which  will  prevent  the 
formation  of  pus  under  that  membrane,  and  consequently  the  death 
of  the  bone.  A  distinguished  man  of  this  city  had  an  injury  of 
the  tibia,  and  the  bone,  or  rather  the  periosteum,  was  inflamed.  I 
made  a  free  incision ;  the  pain  ceased  so  soon  as  the  periosteum  was 
divided,  and  suppuration  was  prevented,  except  what  must  necessarily 
result  from  the  division  of  the  integuments.  The  wound  healed, 
and  he  has  never  experienced  the  slightest  inconvenience  from  the 
injury  or  its  consequences  for  ten  or  fifteen  years. 

In  all  cases  of  periostitis,  if  it  be  possible  to  reach  the  bone,  an 
incision  should  be  made  so  soon  as  the  character  of  the  trouble  can 
be  positively  ascertained.  In  1870  a  gentleman  from  Gold  Hill 
came  to  this  city  with  violent  pain  in  the  mastoid  process,  which  re- 
sisted the  ordinary  treatment,  leeches,  blisters,  and  narcotics,  which 
I  prescribed  without  relief  for  several  days.  I  then  made  an  inci- 
sion, which  extended  to  the  bone,  which  afforded  immediate  relief. 
The  external  wound  was  kept  from  healing,  and  in  fifteen  or  twenty 


LECTURE    XXVIII.  —  CARIES    OF    BONE.  313 

days  several  small  pieces  of  bone  escaped.  The  wound  then  healed, 
and  the  patient  has  been  quite  well  ever  since.  Recently,  in  this 
city,  a  lad,  about  twelve  years  old,  fell  upon  his  side,  and  soon  after- 
wards suffered  violent  pain  in  the  trochanter  major.  Milder  treat- 
ment having  failed  to  relieve  this,  I  made  an  incision  through  the 
skin,  cellular  tissue,  and  periosteum.  The  operation  afforded  imme- 
diate relief;  in  the  course  of  three  weeks  several  small  pieces  of  bone 
escaped,  and  the  young  man  is  now  well.  If  this  case  had  not  been 
properly  treated  this  patient  might  have  been  rendered  a  permanent 
cripple. 

When  a  bone  is  diseased  and  not  necrosed  it  is  called  caries.  This 
difficulty  is  not  uncommon,  and  almost  always  attacks  the  extremities 
of  long  bones,  the  shaft  being  rarely  affected.  It  is  almost  always 
of  a  scrofulous  character,  and  can  be  distinguished  from  tertiary 
syphilis  by  the  location,  the  latter  always  attacking  the  superficial 
bones,  and  the  pain  being  more  severe  at  night.  Do  not  confound 
the  words  necrosis  and  caries ;  the  former  means  a  dead  bone,  the 
latter  a  diseased  bone,  which  may  be  produced  by  a  deposition  of 
tuberculous  matter  in  the  parenchymatous  structure  of  the  bone. 
Inflammation  soon  follows,  pus  of  a  very  unhealthy  character  is 
secreted,  and  when  the  integument  yields  to  the  pressure  you  will 
find  diseased  bone  but  not  a  sequestrum. 

Inflammation  of  the  cancellated  structure  of  a  bone  may  result 
from  violence,  arid  if  not  located  so  that  an  incision  can  be  made 
without  wounding  the  capsule  of  the  joint,  it  must  be  treated  by  the 
ordinary  method.  In  such  cases,  after  the  abscess  breaks  or  is  opened, 
the  abscess  rarely,  and  I  think  I  may  say  that  it  never,  can  heal 
until  the  diseased  bone  is  removed. 

Fig.  69  (p.  314)  represents  the  foot  of  a  little  girl,  about  twelve 
years  of  age,  who  had,  nine  years  previously,  a  scrofulous  affection 
of  the  ankle.  Her  father  died  of  consumption.  A  few  months 
afterwards  the  operation  was  performed  in  the  presence  of  several 
members  of  the  class,  who  were  then  attending  lectures  in  the  med- 
ical college.  She  had  great  pain  in  the  ankle,  with  a  profuse  dis- 
charge from  each  side,  and  was  very  feeble.  I  gave  her  quinine  with 
stimulants,  until  her  general  health  was  improved,  and  then  I  made 
an  incision  over  the  tibia  about  three  inches  long,  and  extending  to 
the  ankle-joint.  Finding  the  bone  enlarged,  I  applied  a  small  tre- 
phine at  the  upper  extremity  of  the  wound,  and  then,  with  a  gouge 


314 


LECTURES  ON  PRACTICAL  SURGERY. 


and  mallet,  the  entire  extremity  of  the  tibia  was  removed,  but  the 
periosteum  was  preserved. 


FIG.  69. 


From  this  operation  she  recovered  rapidly,  and  in  four  or  five 
weeks  I  made  an  incision  upon  the  external  side  of  the  ankle-joint, 
and  removed  with  a  chain-saw  the  lower  extremity  of  the  fibula, 
and  all  the  bones  of  the  ankle-joint  with  a  pair  of  tooth  forceps. 
She  recovered  rapidly,  has  perfect  use  of  the  joint,  is  as  active  as 
ordinary  children  of  her  age,  and  for  several  years  did  not  require  any 
support,  but  recently  she  complained  that  the  injured  foot  was  weaker 


LECTURE    XXVIII. — OPERATIONS    FOR    CARIES.  315 

than  the  other.  I  supplied  her  with  a  support,  which  she  will  use 
until  she  is  fully  matured.  This  case  was  presented  at  a  meeting  of 
the  State  Medical  Society,  in  San  Francisco,  but  not  until  ten  years 
had  elapsed  after  the  performance  of  the  operation.  Bones  have 
been  reproduced  in  this  case, — three  inches  of  the  tibia,  one  inch 
and  a  half  of  the  fibula,  with  all  the  bones  of  the  ankle-joint;  and 
now  the  limb  is  very  little  shortened  ;  the  motion  of  the  joint  is  per- 
fect, consequently  the  articulating  surfaces  and  ligaments  must  also 
exist,  otherwise  there  could  neither  be  strength  nor  useful  motion. 
A  few  months  after  this  operation  was  performed  I  removed  at  my 
private  hospital  the  entire  ulna  for  necrosis,  with  the  most  satis- 
factory result.  The  patient  was  from  Benicia,  was  about  thirteen 
years  old,  and  made  as  rapid  and  satisfactory  recovery  as  any  pa- 
tient I  have  ever  treated  for  a  similar  difficulty. 

I  operated  upon  Mrs.  Bruze,  a  clergyman's  wife,  from  Coloma, 
for  caries  of  the  ankle-joint  which  involved  the  bones  of  the  leg. 
Her  weight,  when  she  came  to  San  Francisco,  was  seventy-five 
pounds.  Not  only  the  lower  extremities  of  the  tibia  and  fibula  were 
removed,  but  also  all  the  bones  of  the  ankle-joint,  and  to  the  aston- 
ishment of  all  her  friends  she  has  so  far  recovered  as  not  to  require 
even  a  cane,  and  is  able  to  attend  to  all  her  domestic  duties  without 
any  inconvenience.  I  will  not  trespass  upon  your  time  by  giving 
other  cases,  but  I  want  you  distinctly  to  understand  that  when  you 
can  remove  all  the  dead  bone  either  from  a  joint  or  the  shaft  of  a 
bone,  it  is  much  more  safe  and  the  result  is  always  more  satisfactory 
than  an  amputation. 

You  will  read  of  subperiosteal  resections  of  bones.  No  man  can 
dissect  the  periosteum  from  a  healthy  elbow-joint,  and  resect  the  joint 
after  the  periosteum  has  been  removed,  and  in  every  case  the  opera- 
tion has  proved  a  failure.  No  man  can  remove  the  periosteum  so 
well  and  so  effectually  as  inflammation  does,  consequently  in  diseases 
of  the  bones,  if  the  primary  treatment  does  not  succeed,  then  I  beg 
leave  to  recommend  patience.  Wait  until  the  periosteum  separates 
from  the  bone,  then  the  diseased  bone  can  be  removed.  A  new  bone 
will  be  formed  by  the  periosteum,  which  may  be  as  useful  as  the 
original.  I  wish  you  to  distinctly  understand  that  a  bone  covered 
by  the  periosteum  should  not,  under  any  circumstances,  be  removed, 
and  I  am  convinced  from  observation  that  whenever  resections  have 
been  attempted  in  such  cases  they  have  proved  to  be  failures. 


316  LECTURES    ON    PRACTICAL    SURGERY. 

Subcutaneous  resections  of  bones  are  very  fashionable,  but  unless 
the  term  refers  to  bones  denuded  by  disease,  I  have  no  confidence  in 
the  success  of  such  operations.  Should  an  articulation  be  diseased 
without  the  bone  being  implicated,  then  open  the  joint,  remove  the 
articulating  surfaces,  and  treat  the  case  according  to  the  directions 
already  given  for  the  management  in  ordinary  cases  of  resection. 
Do  not  disturb  the  periosteum  of  a  healthy  bone,  and  never  resect 
anything  except  the  articulating  surfaces.  In  a  matter  of  so  much 
importance  repetition  I  think  is  excusable.  Tubercles  may  form  in 
any  portion  of  the  body,  and  the  cancellated  portion  of  long  bones 
is  liable  to  this  occurrence.  Sometimes  the  presence  of  tubercles  pro- 
duces inflammation.  Purulent  matter  is  secreted,  and  not  finding 
an  exit  the  bone  expands,  becomes  occasionally  enormously  enlarged, 
and  a  condition  results  which  was  formerly  called  spina  ventosa. 
The  bone  becomes  diseased,  generally  from  an  injury,  the  periosteum 
separates,  a  new  bone  is  formed,  and  in  consequence  of  the  pressure 
of  the  contained  fluid  becomes  greatly  enlarged. 

I  treated  a  case  of  this  character  at  the  Franklin  House,  on 
Broadway,  a  few  years  ago.  The  lower  extremity  of  the  thigh-bone 
was  enormously  enlarged.  The  articulation  not  being  involved,  I 
applied  the  trephine,  which  allowed  more  than  a  quart  of  pus  to  es- 
cape, used  the  warm-water  dressing  with  a  tight  bandage,  and  was 
greatly  pleased  to  hear,  two  or  three  years  subsequently,  that  the  boy 
had  entirely  recovered,  the  enlargement  having  disappeared.  Oc- 
casionally pus  forms  in  the  interior  of  a  bone,  and  remains  many 
years  without  producing  any  external  evidence  of  disease,  but  is  ac- 
companied with  the  most  excruciating  pain.  The  most  remarkable 
case  of  this  character  that  I  have  treated  came  from  Oregon.  He 
was  a  German,  aged  about  forty  years.  His  father  was  a  farrier,  and 
one  afternoon  when  he  and  some  other  boys  were  amusing  them- 
selves by  sliding  down  the  side  of  a  pile  of  straw,  it  so  happened 
that  instead  of  his  coming  in  contact  with  straw,  he  struck  upon  the 
ground  with  some  force.  From  that  time  he  had  pain  in  the  tibia  of 
the  right  leg.  The  pain  occasionally  became  excessive,  then  he  was 
confined  to  bed,  blisters  were  applied  and  anodynes  administered, 
which  afforded  only  temporary  relief.  After  making  a  careful  ex- 
amination of  his  case,  I  was  in  doubt  as  to  its  true  character.  The 
superficial  nerves  of  the  leg  were  divided  without  relief.  I  then 
came  to  the  conclusion  that  the  cause  was  in  the  centre  of  the  bone, 


LECTURE    XXVIII. — TUMORS    OF    BONE.  317 

and  accordingly  applied  the  trephine,  when  to  my  gratification  and  his 
immediate  relief  more  than  a  teaspoonful  of  pus  escaped.  That 
collision  had  probably  existed  more  than  twenty  years,  and  yet  had 
not  produced  the  slightest  enlargement  of  the  bone.  This  case  was 
published  at  the  time,  in  the  Pacific  Medical  Journal,  with  all  the 
necessary  details. 

Exostosis  means  an  unnatural  growth  of  a  bone.  It  may  be 
solid,  hollow,  or  formed  of  radiating  plates.  Sometimes  an  ex- 
ostosis  is  excessively  hard,  particularly  in  tertiary  syphilis,  when  it 
is  as  firm  as  ivory  and  is  said  to  be  eburnated.  Sometimes  the  en- 
largement rises  abruptly,  and  then  it  is  called  a  node,  which  is  the 
form  generally  presented  in  specific  affections  of  the  periosteum. 
After  the  inflammation  has  existed  for  some  time,  an  indistinct  fluc- 
tuation is  discovered,  and  if  an  opening  be  made,  a  thin  yellow  matter 
escapes  which  can  scarcely  be  called  purulent.  This  is  generally 
followed  by  an  exfoliation  of  the  bone,  to  which  our  attention  will 
be  directed  when  I  lecture  upon  that  subject.  Exostoses  may  occur 
from  other  causes.  They  are  often  found  upon  the  shaft  of  a  bone, 
particularly  in  the  humerus  and  femur ;  they  give  no  pain,  are  not 
tender  to  the  touch,  and  very  often  the  patient  does  not  know  how 
long  they  have  existed.  They  are  not  dangerous,  and  can  be  re- 
moved either  with  a  gouge  or  chisel,  or,  if  in  a  favorable  location, 
with  a  chain-saw. 

When  situated  either  in  the  medullary  or  cancellated  structure  of 
a  bone,  they  are  usually  called  osteosarcoma,  and  are  divided  into 
fibrous  and  medullary.  They  occur  frequently  in  the  bones  of  the 
face,  and  particularly  in  the  superior  and  inferior  maxillary  bones. 
It  is  not  necessary  to  repeat  what  was  said  upon  this  subject  when 
lecturing  on  tumors.  Encephaloid  or  malignant  cancer  frequently 
affects  the  bones  of  young  persons,  and  is  always  fatal.  Your  at- 
tention has  also  been  directed  to  this  disease.  Rickets  is  a  disease 
of  the  bones  to  which  I  have  not  alluded.  In  this  affection  the 
bones  are  soft,  resembling  leather  rather  than  bone.  If  you  pass  a 
saw  either  transversely  or  perpendicularly  through  such  a  bone,  fhe 
surface  exposed  is  red  instead  of  white.  The  bone  can  be  bent  in 
any  direction,  and  when  fractured  it  yields  no  crepitation,  but  if  the 
limb  be  examined  in  a  few  days  afterwards,  you  will  find  at  the 
point  injured  an  enlargement.  The  bone  was  bent  at  that  point, 
but  there  was  no  displacement.  There  are  two  families  in  this  city 


318  LECTURES    ON    PRACTICAL    SURGERY. 

that  I  have  attended  for  the  last  twenty  years,  and  all  the  first  chil- 
dren had  rickets  with  bent  legs  and  easily  injured  bones.  This  con- 
tinued until  I  ascertained  the  cause.  After  this  the  children  were 
not  allowed  to  take  any  except  coarse  food,  which  contained  a  suffi- 
cient amount  of  the  phosphates,  and  was  taken  into  the  stomach  to 
render  the  bones  solid.  Give  corn-meal,  sweet  potatoes,  oatmeal, 
cracked  wheat,  or  brown  bread  with  beef,  and  this  disease  will 
disappear  in  a  very  short  time.  If  this  course  of  treating  children 
was  generally  adopted,  the  human  race  would  improve  rapidly,  both 
physically  and  mentally,  and  very  soon  bow  legs  and  hunchbacks 
would  disappear. 

Mollities  ossium  is  a  disease  in  which  the  bones  are  easily  bent, 
but  do  not  contain  lime  enough  to  actually  break.  This  disease  is 
confined  to  adults,  and  I  am  truly  glad  to  say  to  you  that  I  have 
practiced  medicine  over  thirty  years  without  meeting  with  a  case  of 
this  character.  I  hope  you  will  not  misunderstand  me.  I  am  glad 
to  know  that  the  disease  occurs  so  seldom.  Yet  if  a  case  should  occur 
in  this  city  I  would  appreciate  highly  the  privilege  of  examining  it, 
so  as  to  determine  if  possible  the  true  cause  and  character  of  the  diffi- 
culty. Such  patients  generally  suffer  excessively,  and  require  nar- 
cotics to  obtain  relief.  I  think  from  the  experience  of  other  compe- 
tent men,  that  this  disease  is  incurable.  Yet  you  should  do  everything 
possible  to  render  your  patient  comfortable,  and  endeavor  to  ascertain 
the  cause  of  the  disease  by  examining  the  excretions,  as  well  as  ob- 
taining a  knowledge  of  his  habits. 


LECTURE    XXIX.  —  DISEASE    OF    THE    SPINE.  319 

A 


/*» 


LECTURE    XXIX. 

v-v/4, 

GENTLEMEN:  Diseases  of  the  spine  may  result  from  either  one  of 
two  morbid  conditions,  the  symptoms  of  which  it  is  exceedingly  im- 
portant for  you  to  recognize.  The  first  is  preceded  by  a  deposition 
of  crude  tuberculous  matter,  the  presence  of  which,  in  the  cancellated 
structure  of  the  bones,  always  produces  inflammation  ;  as  the  re- 
sult of  this  the  vertebrae  become  carious,  their  anterior,  lateral,  or 
posterior  portions  are  absorbed,  and  in  this  way  the  vertebral  column 
is  weakened.  If  the  vertebral  column  has  been  divided  perpendicu- 
larly by  a  saw,  we  observe  a  deficiency  in  the  anterior  portion,  for 
example,  of  the  bodies  of  the  bones,  and  whenever  this  condition 
exists,  what  remains  of  the  bones  will  come  in  contact  and  a  pos- 
terior curvature  must  result.  Suppose  the  caries  should  occur  lat- 
erally, then  the  body  will  be  curved  in  the  opposite  direction,  which 
is  called  a  lateral  curvature.  The  spine  may  curve  to  either  side, 
anteriorly  or  posteriorly,  according  to  the  portion  of  the  body  of  the 
vertebrae  that  may  be  destroyed.  This  is  an  exceedingly  important 
and  difficult  disease  to  treat,  and  its  symptoms  differ  entirely  from 
those  of  the  simple  form. 

The  patient  generally  has  fever,  complains  ofjpain  in  the  back, 
and  is  unwilling  to  take  much  exercise.  Often  these  symptoms  are 
accompanied  with  numbness  of  the  lower  extremities,  and  sometimes 
with  paralysis.  After  this  condition  has  continued  for  a  time,  the  cur- 
vature will  become  apparent,  and  sometimes  a  fluctuating  tumor  will 
be  detected,  and  the  pain  is  temporarily  diminished.  This  tumor 
may  appear  near  the  curvature,  at  the  groin,  or  above  the  knee ; 
when  near  the  spine  it  is  called  a  spinal  or  lumbar  abscess,  when  at 
the  groin  a  psoas  abscess,  because  the  pus  passes  down  the  sheath 
of  the  psoas  magnus  muscle,  until  it  reaches  that  point,  but  occa- 
sionally it  passes  under  the  fascia  lata  until  it  reaches  the  knee. 

Be  careful  not  to  make  an  opening  so  soon  as  you  discover  fluc- 
tuation. The  abscess  is  an  evidence  of  organic  disease  of  the  bone, 
and  should  not  be  opened  as  long  as  it  can  possibly  be  avoided.  I  saw 


320  LECTURES    ON    PRACTICAL    SURGERY. 

Lisfranc,  in  the  Hospital  of  La  Pitie,  open  a  psoas  abscess,  and  then 
apply  twenty  leeches  about  the  opening — the  most  effectual  method 
that  could  be  adopted  to  destroy  the  patient.  In  this  city  some 
physicians  insert  a  drainage-tube,  but  I  must  say  that  my  experience 
forbids  any  interference.  So  long  as  the  air  is  excluded  from  the 
cavity  of  the  abscess,  there  is  but  little  fever,  the  patient  is  comfort- 
able, has  a  good  appetite,  and  some  chance  remains  for  his  recovery. 

In  Dupuytren's  ward,  in  the  Hotel  Dieu,  in  Paris,  I  saw  two  cases 
treated  and  relieved  by  counter  irritation  and  constitutional  treatment. 
The  moxa'was  applied  repeatedly;  the  abscess  disappeared,  but  I 
am  not  positive  that  the  cure  was  permanent.  When  a  psoas  abscess 
has  been  opened,  I  have  never  known  a  patient  to  recover,  although 
they  sometimes  linger  for  several  years  before  they  are  completely 
exhausted  by  the  drain.  When,  however,  the  skin  covering  an 
abscess  becomes  inflamed,  and  ulceration  is  threatened,  an  opening 
should  be  made  to  relieve  the  distension.  I  think  the  method 
adopted  when  I  was  a  student  greatly  preferable  to  a  free  incision. 
A  valvular  opening  was  made,  and  after  the  escape  of  the  pus  the 
incision  was  closed  by  the  first  intention,  and  the  operation  re- 
peated when  necessary.  In  caries  of  the  spine  with  curvature,  great 
benefit  will  result  from  the  use  of  a  properly  adjusted  apparatus,  cal- 
culated to  relieve  the  spine  from  the  weight  of  the  upper  part  of 
the  body,  and  prevent  the  increase  of  the  deformity.  Such  machines 
are  now  made  in  this  city  quite  as  well  as  in  any  other  por- 
tion of  the  United  States.  Tonics  should  be  prescribed,  generous 
diet  allowed,  and  indeed  every  means  employed  to  increase  the 
strength  of  the  patient.  Cod  liver  oil  is  a  favorite  remedy  with 
many  members  of  the  profession  in  such  cases,  but  I  must  say  that 
I  have  always  been  disappointed  when  it  was  prescribed.  Blan- 
card's  pills  are  very  valuable,  and  I  have  long  thought  the  opinion 
of  Trousseau  (who  was  one  of  my  teachers  when  in  Paris),  that  the 
preparations  of  iron  favored  the  development  of  tubercles,  was 
wanting  in  proof. 

In  curvature  of  the  spine  produced  by  rickets  or  by  general  con- 
stitutional and  local  debility,  we  may  by  proper  management  pre- 
vent the  deformity  from  increasing,  and  sometimes  cure  it  after  it 
has  occurred.  A  suitable  apparatus  should  be  applied,  particularly 
during  exercise.  If  it  is  disagreeable  to  the  patient,  the  instrument 
may  be  removed  from  time  to  time,  and  then  the  horizontal  posture 


LECTURE    XXIX. — CURVATURE    OF    SPINE.  321 

should  be  enforced.  I  have  cured  some  very  bad  cases  by  com- 
bining rest,  exercise,  and  proper  diet.  There  are  now  in  this  city 
two  young  ladies  in  fine  health,  who  were  cured  without  an  appara- 
tus, by  exercising  with  weight  and  pulley,  and  spending  the  balance 
of  the  day  on  a  lounge,  with  a  pillow  under  the  prominent  portion 
of  the  spine.  This  plan  I  adopted  about  twenty-five  years  ago, 
and  have  not  failed  in  a  single  case  in  which  the  patient  was  old 
enough  to  appreciate  the  necessity  of  perseverance. 

In  the  two  cases  above  alluded  to  the  curvature  was  lateral,  and 
only  three  months'  treatment  was  required  to  efreet  a  radical  cure. 
In  a  posterior  curvature  of  this  character  it  is  not  necessary  to  de- 
prive the  patient  of  liberty.  Apply  a  suitable  apparatus ;  allow 
them  to  take  exercise,  to  go  to  school,  and  feed  and  clothe  them 
properly,  and  in  almost  every  case  the  curvature  will  disappear. 
Sulphate  of  quinine,  with  the  fluid  extract  of  senna,  has  produced  a 
more  decided  tonic  effect  in  such  cases  than  any  other  combination 
I  have  ever  made.  In  such  cases  specialists  rely  too  much  upon 
apparatus.  A  practitioner  of  this  kind  visited  this  city  a  few  years 
ago,  but  I  do  not  think  he  increased  his  reputation  by  his  visit. 

There  was  a  little  boy  here,  two  or  three  years  old,  who  was  doing 
exceedingly  well  under  judicious  treatment.  This  man  applied  an 
apparatus  which  the  poor  little  fellow  could  not  carry.  His  health 
after  the  machine  was  applied  failed  daily,  until  it  was  removed  and 
the  former  treatment  resumed,  and  he  is  now  well.  If  there  is  any 
character  I  abominate,  it  is  one  of  these  machine  specialists  who  has 
not  brains  enough  to  become  familiar  with  every  branch  of  the  pro- 
fession. He  may  devote  his  attention  to  orthopedic  surgery  without 
ever  having  treated  a  patient. 

I  have  already  described  the  treatment  of  rickets,  and  need  not 
therefore  speak  further  upon  this  subject,  except  to  say,  give  food 
that  increases  the  formation  of  the  phosphate  of  lime  in  the  blood, 
without  which  the  disease  cannot  be  cured.  In  cases  of  curvature 
of  the  spine  it  is  much  better  for  a  patient  to  walk  than  to  remain 
long  in  a  sitting  posture,  with  all  the  muscles  relaxed  and  the 
weight  falling  upon  the  spine. 

When  children  are  disposed  to  curvatures  of  the  spine,  in  con- 
sequence of  being  confined  too  long  in  school,  or  being  allowed 
to  sleep  with  the  head  too  high,  the  cause  should  be  removed, 
tonics  administered,  and  the  proper  diet  prescribed  to  increase  the 

21 


322  LECTURES    ON    PRACTICAL    SURGERY. 

strength  of  the  bones.  There  is  nothing  so  injurious  in  such  cases 
as  the  ordinary  shoulder-brace.  The  shoulders  are  drawn  back,  but 
the  position  of  the  spine  remains  the  same.  The  muscles  become 
weakened  by  inaction.  Nor  do  I  believe  in  such  cases  in  making 
extension  or  counterextension.  This  treatment  is  very  distressing, 
and  I  have  yet  to  meet  with  the  first  case  in  which  great  deformity 
existed  that  has  been  entirely  cured.  Such  cases  should  be  at- 
tended to  early,  before  the  deformity  becomes  so  great  as  to  be  in- 
curable. This  is  an  exceedingly  important  subject,  because  you 
will  have  an  opportunity  to  use  the  knowledge  you  may  acquire  very 
frequently.  It  occurs  oftenest  in  cities,  and  I  think  San  Francisco 
affords  as  many  cases  in  proportion  to  the  population  as  any  city  in 
the  world,  because  we  have  very  little  warm  weather.  The  poorer 
classes,  in  consequence  of  the  scarcity  of  houses,  have  heretofore  been 
too  much  crowded,  and  they  have  too  much  baker's  bread,  butter, 
and  Irish  potatoes  to  obtain  a  solid  and  perfect  development. 

Sprains  and  bruises  are  very  important  to  the  general  practitioner, 
and  should  follow  the  consideration  of  spinal  affections,  because  the 
bones,  ligaments,  and  joints,  are  almost  exclusively  implicated.  As 
before  stated,  the  osseous  and  ligamentous  tissues,  when  in  a  healthy 
condition,  are  almost  entirely  devoid  of  sensibility,  but  when  strained, 
that  is  when  stretched  or  contused,  they  sometimes  become  exceed- 
ingly painful.  The  hinge-joints  suffer  most  from  strains,  such  as  the 
knee,  ankle,  and  joints  of  the  fingers  and  toes.  Sometimes  a  strain 
is  followed  by  consequences  more  serious  than  a  compound  dislo- 
cation of  the  ankle-joint.  Two  prominent  citizens  were  riding  in 
the  same  buggy  on  Stockton  Street,  when  the  buggy  capsized  and 
they  were  both  thrown  out ;  one  had  a  compound  dislocation  of  the 
fibula,  and  the  other  a  strained  ankle ;  the  former  was  well  in  six 
weeks,  the  latter  was  quite  lame  for  more  than  a  year. 

I  have  mentioned  these  cases  for  the  purpose  of  showing  that  such 
injuries,  without  either  a  fracture  or  dislocation,  may  prove  serious, 
and  should  not  be  neglected.  Some  years  since,  in  stepping  from 
my  buggy  carelessly,  my  foot  came  in  contact  with  a  brick  which 
turned  and  strained  the  ligament  connecting  the  tarsal  and  meta- 
tarsal  bones  of  the  little  toe,  as  well  as  the  ankle-joint  on  the  outer 
side.  The  pain  was  acute,  the  foot  swelled  rapidly,  and  I  was  lame 
for  several  days  from  that  apparently  slight  injury,  which,  neglected, 
might  have  been  followed  by  serious  consequences.  After  a  strain 


LECTURE    XXIX.  —  SPRAINS.  323 

inflammation  may  supervene  and  involve  both  the  synovial  mem- 
brane and  the  periosteum.  The  pain  in  such  cases  is  sometimes 
exceedingly  violent.  Leeches  should  be  applied,  or  a  number  of 
punctures  made  to  cause  a  sufficient  loss  of  blood  to  relieve  the  dis- 
tended vessels  of  the  part.  If  the  injury  is  not  serious,  cold  water 
may  be  applied  during  the  day,  or  an  evaporating  lotion  com- 
posed of  alcohol  5ij,  and  aqua  font.  5xij,  or  a  solution  of  acetate 
of  lead;  but  at  night  I  prefer  the  following  mixture:  plumb, 
acet,  5iv ;  tinct.  opii,  §ij ;  tinct.  arnica?,  §iv ;  aquae  font.,  a  quart. 
Four  or  five  double  of  flannel  or  soft  old  linen  should  be  saturated 
with  this  mixture  and  applied,  covered  carefully  with  oiled  silk  and 
secured  by  a  roller  bandage.  If  this  application  does  not  afford  im- 
mediate comfort,  direct  that  a  fourth  of  a  grain  of  the  sulphate  of 
morphia  be  administered  every  hour  to  an  adult  male  until  relief  is 
obtained.  The  patient  is  so  much  better  by  morning  that  he  gen- 
erally insists  on  discarding  the  evaporating  lotion  and  cold  water, 
and  desires  to  continue  the  use  of  the  mixture  already  given. 
Should  an  injury  only  produce  a  contusion  of  the  skin,  subcutaneous 
tissue,  and  muscle,  and  be  accompanied  with  violent  pain,  the  fol- 
lowing mixture  will  afford  almost  instantaneous  relief:  ol.  terebinth., 
Siv;  tinct.  aconiti  rad.,  chloroform,  aa  5vj ;  gum  camph.,  5iij.  M. 
Apply  5vj  to  the  part,  rub  gently  for  some  minutes,  or  until  the 
mixture  either  evaporates  or  is  absorbed.  When  the  contusion  is 
sufficiently  violent  to  cause  suppuration,  an  opening  should  be  made 
so  soon  as  fluctuation  is  distinct.  Should  the  contusion  be  so  violent 
as  to  produce  destruction  of  the  articulating  surfaces,  the  only  al- 
ternatives left  are  a  resection  of  the  joint  or  anchylosis,  which 
sometimes  results  from  keeping  bones  in  contact  which  have  by  in- 
flammation been  deprived  of  their  articulating  surfaces.  I  will 
present  a  photograph  of  the  foot  of  a  gentleman  from  Stockton,  who 
came  to  this  city  to  have  his  leg  amputated.  I  persuaded  him  to 
allow  me  to  remove  the  diseased  bones.  I  removed  at  the  first  oper- 
ation the  metatarsal  bones,  and  when  he  recovered  from  that,  all 
the  bones  of  the  ankle-joint,  including  the  os  calcis.  In  a  few  days 
his  diarrhrea  ceased,  the  appetite  returned,  and  in  three  or  four 
months  he  returned  to  Stockton,  with  anchylosis  of  the  joint,  but 
with  a  sound  and  useful  foot  and  leg. 

A  gentleman,  a  few  years  since,  came  from  Humboldt  County,  in 
this  State,  with  caries  of  all  the  bones  of  the  ankle-joint.     They 


324  LECTURES   ON    PRACTICAL    SURGERY. 

were  all  removed  with  an  exceedingly  fortunate  result,  and  if  the 
injury  had  received  proper  attention  at  first,  the  difficulty  never 
would  have  become  so  serious.  The  joints  are  occasionally  wounded, 
and  when  they  are,  you  should  always  regard  the  lesion  as  one  of 
an  exceedingly  serious  character ;  if  you  do  not  recollect  how  you 
have  been  directed  to  treat  such  a  difficulty,  you  should  ask  for  a 
consultation.  The  synovial  fluid  should  be  removed,  the  wound 
should  be  closed  by  silver  sutures,  and  a  long  splint  placed  upon 
the  back  of  the  leg  and  kept  constantly  applied  until  union  by  the 
first  intention  has  occurred.  When  you  are  satisfied  that  the  wound 
has  healed,  remove  the  sutures  and  allow  the  patient  to  use  the  joint, 
so  as  to  prevent  anchylosis.  I  treated  a  man,  aged  about  forty  years, 
who  had  been  drunk  for  about  a  week,  and  while  in  that  condition 
had  fallen  against  a  box  from  which  a  nail  projected,  and  was  forced 
into  the  knee-joint.  He  continued  to  drink  for  several  days,  and 
when  I  was  called  by  his  employers,  his  knee-joint  was  immensely 
swollen,  very  painful,  and  so  much  diseased  that  his  friends  had 
very  little  hope  of  his  recovery.  I  placed  his  leg  upon  a  double 
inclined  plane.  Hot-water  dressings  were  applied  constantly,  and  a 
sufficient  amount  of  sulphate  of  morphia  was  administered  to  re- 
lieve pain.  When  the  limb  was  placed  upon  the  splint,  about  a 
pint  of  unhealthy  synovial  fluid  escaped  daily  from  the  knee-joint, 
yet  in  three  weeks  the  wound  was  healed,  and  he  left  San  Francisco 
without  even  thanking  me  for  the  most  remarkable  and  unexpected 
cure  that  ever  occurred  either  in  this  or  any  other  city. 

I  attribute  the  result  to  the  position  of  the  limb  and  the  constant 
use  of  morphia*  The  pain  was  relieved  at  once,  and  he  was  not 
allowed  to  suffer  at  all  during  the  time  he  was  confined  to  bed. 
After  the  second  week  the  joint  was  moved  once  a  day,  until  perfect 
motion  was  restored.  I  was  then  a  stranger  in  San  Francisco,  and 
invited  several  physicians  to  examine  the  patient ;  there  is  but  one 
now  living  of  those  who  saw  him.  Should  extensive  laceration 
exist,  and  the  tendons  and  bones  be  torn  and  mangled  to  such  an 
extent  that  the  limb  can  never  be  useful,  it  should  be  removed,  for 
if  it  be  allowed  to  remain,  tetanus  might  occur,  and  in  any  event, 
the  patient  after  long  suffering  would  not  have  a  limb  worth  the 
trouble  and  risk  it  cost  to  save  it.  In  this  connection  I  will  refer  to 
inflammation  of  the  joints,  which  may  result  from  injuries,  strains, 
contusions,  or  exposure  to  cold.  In  rheumatic  affections  produced 


LECTURE    XXIX.  —  INFLAMMATION    OF    JOINTS.  325 

by  cold,  of  course  you  will  employ  the  remedies  which  have  been 
found  most  useful  in  such  cases.  And  as  we  may  not  have  occasion 
to  refer  to  this  subject  again,  I  will  give  you  the  best  combination 
of  medicines  that  has  ever  been  suggested:  Potass,  iodidi,  5iv; 
vin.  colch.  sem.,  §iss. ;  tinct.  aconiti  rad.,  5iss. ;  ext.  acteae  racernosse 
fol.  (cohosh),  Siij  ;  syr.  zingiberis,  Siss.  Misce.  Sig.  Take  one  tea- 
spoonful  four  times  in  twenty-four  hours,  with  a  quarter  or  half  a 
grain  at  night  of  sulphate  of  morphia,  to  relieve  pain  and  produce 
sleep.  Professor  Flint,  Sr.,  differs  from  me,  but  I  still  hope  that 
he  will  condescend  to  try  the  favorite  remedy  of  a  California  physi- 
cian, and  then  publish  in  his  next  edition  the  result  of  his  experi- 
ence. In  scrofulous  inflammation  of  the  joints,  the  disease  is  called 
white  swelling,  because  there  is  no  discoloration  of  the  skin. 
When  inflammation  of  the  synovial  membrane  exists,  it  is  rendered 
evident  by  the  fluctuating  enlargement  of  the  joint,  the  increase  of 
the  synovial  secretion  producing  fluctuation.  When  the  disease  is 
not  controlled  by  the  use  of  the  specifics  in  such  cases,  such  as  the 
iodide  of  potassium,  iodide  of  iron,  quinine,  or  any  of  the  remedies 
usually  prescribed,  even  the  much  overrated  cod-liver  oil,  then  I 
always  endeavor  to  produce  anchylosis  by  placing  the  limb  in  the 
most  favorable  position,  should  that  occur.  This  treatment  is  ap- 
plicable only  to  the  knee  and  elbow-joints.  When  I  had  charge  of 
the  United  States  Marine  Hospital,  in  1854,  a  sailor  was  admitted 
with  complete  anchylosis  of  all  the  joints  of  the  lower  extremities. 
He  was  young,  and  willing  to  submit  to  any  treatment  in  order  to 
obtain  relief.  I  had  chloroform  administered,  and  all  the  force 
which  I  thought  was  proper  to  apply  was  used,  but  the  joints  re- 
sisted. Soon  afterwards  he  left  the  hospital,  disappeared,  and  I  have 
not  seen  him  since.  In  the  treatment  of  such  cases,  unless  you  desire 
to  produce  anchylosis,  the  joint  should  be  flexed  and  extended  every 
two  or  three  days.  In  Europe,  in  consequence  of  the  unwillingness 
of  such  patients  to  take  exercise  enough  to  prevent  anchylosis,  they 
have  in  every  hospital  a  room  with  a  metallic  perforated  floor, 
which  is  heated  to  such  a  point  that  a  patient  is  unable  to  stand 
upon  it  a  minute,  but  by  constant  motion  the  heat  is  not  sufficiently 
great  to  burn.  This  course  of  treatment  is  universally  adopted  in 
old  cases  of  chronic  rheumatism,  and  many  which  were  regarded  as 
incurable  have  been  rendered  useful  members  of  society.  When  I 
had  charge  of  the  United  States  Hospital,  in  this  city,  a  man  was 


S26  LECTURES    ON    PRACTICAL    SURGERY. 

found  there  whose  feet  were  so  sensitive  that  they  had  not  borne  his 
weight  for  two  years.  The  soles  were  greatly  thickened,  and  he 
would  not,  unless  forced,  place  his  feet  upon  the  floor.  I  had  him 
taken  out  of  bed  by  two  strong  men,  and  compelled  him  to  walk  an 
hour,  morning  and  evening;  in  a  few  days  he  acquired  sufficient 
confidence  to  leave  the  bed  himself.  In  three  or  four  months  he 
left  the  hospital  perfectly  well,  and  was  no  doubt  as  good  and  active 
a  sailor  as  was  ever  shipped  from  this  coast.  In  such  cases  patients 
should  not  be  indulged;  so  soon  as  the  acute  inflammation  subsides, 
exercise  of  the  joints  should  be  recommended  and  insisted  upon, 
until  the  soreness  and  stiffness  entirely  disappear.  In  chronic  af- 
fections of  the  knee-joint  I  administer  tonics — apply  counterirritants, 
such  as  croton  oil,  blisters,  tincture  of  iodine,  or  the  ol.  terebinth, 
liniment,  which  I  usually  prescribe  when  the  pain  is  violent,  and  I 
think  it  relieves  pain  more  speedily  than  any  application  which  I 
have  ever  made.  When  acute  inflammation  subsides,  and  some  in- 
duration remains,  tincture  of  iodine  and  arnica,  equal  parts,  should 
be  applied  twice  every  day  with  a  camePs-hair  pencil  until  the  in- 
duration disappears.  When  the  enlargement  of  the  joint  resists  in- 
ternal treatment,  the  application  of  the  tincture  of  iodine  and  arnica, 
I  would  advise  what  is  called  an  elastic  knee-cap  ;  when  applied  it 
produces  permanent  pressure,  which  increases  the  action  of  the  ab- 
sorbents more  than  any  other  remedy  or  combination  of  remedies 
that  ever  was  administered.  Should  the  bandage  fail  to  increase  the 
action  of  the  absorbents,  then  the  knee  should  be  padded  with  cotton 
so  as  to  increase  the  pressure  of  the  bandage. 


LECTURE    XXX.  —  WOUNDS    OF    JOINTS.  327 


LECTURE   XXX. 

GENTLEMEN  :  In  my  last  lecture  I  spoke  of  lacerated  wounds  of 
the  joints.  To-day  I  will  describe  other  difficulties  with  which  you 
may  have  to  contend. 

Incised  wounds  of  the  knee-joint,  although  not  frequent,  occasion- 
ally occur ;  in  every  instance  I  have  seen,  the  wound  was  produced 
by  a  tool  called  the  foot-adze,  a  dangerous  instrument  even  in  the 
hands  of  a  skilful  carpenter.  In  such  cases,  remove  from  the  wound 
all  the  synovial  fluid,  insert  as  many  points  of  interrupted  silver 
suture  as  will  close  it,  in  other  words  to  bring  and  hold  the  edges 
together  until  they  unite,  so  as  to  prevent  the  escape  of  the  synovia. 
In  dressing  such  wounds,  always  make  provision  for  the  escape  of 
the  bloody  serum  which  necessarily  results  from  a  solution  of  con- 
tinuity. Apply  either  the  warm- water  dressing  or  simple  cerate. 
Never  apply  to  such  a  wound  dry  lint,  adhesive  plaster,  or  collodion. 
If  an  incised  wound  of  the  knee  or  any  other  joint  be  treated  as  in- 
dicated, and  the  part  be  kept  quiet,  it  almost  always  heals.  Should 
the  ankle-joint  be  wounded,  the  water  dressing  should  be  applied,  a 
compress  of  cotton  placed  over  the  wound,  and  a  splint  on  one  side 
of  the  joint,  which  can  be  secured  by  the  same  bandage  that  retains 
the  compress  in  its  proper  position.  In  wounds  of  the  knee-joint, 
after  pursuing  the  course  before  given,  a  long  splint  should  be  placed 
upon  the  back  of  the  thigh  and  leg,  and  retained  until  the  wound 
heals  and  the  sutures  have  been  removed.  I  rarely  remove  the 
sutures,  which  should  always  be  of  silver  wire,  before  the  eighth  day, 
and  sometimes  they  are  allowed  to  remain  longer  if  no  evidence  of 
ulceration  exists. 

When  I  entered  the  profession,  it  was  supposed  that  if  a  joint 
was  opened,  it  was  impossible  either  to  save  the  limb  or  to  restore 
its  usefulness.  It  is  now  known  to  every  good  surgeon  that  a  joint 
may  be  opened  by  either  a  punctured,  lacerated,  or  incised  wound, 
and  the  patient  may  recover  the  perfect  use  of  the  joint,  and  the 
limb  become  as  useful  as  before  the  occurrence  of  the  injury,  pro- 


328  LECTURES    ON    PRACTICAL    SURGERY. 

vided  he  receives  proper  medical  and  surgical  treatment.  But  when 
inflammation  does  follow  lacerated  wounds  of  the  joints,  if  active 
remedies  are  not  employed,  serious  pathological  changes  speedily 
follow.  You  should  resort  to  irrigation  until  the  inflammation  has 
subsided,  and  then  warm- water  dressings  should  be  applied  to  pro- 
mote granulations,  which  must  be  developed  before  cicatrization  can 
take  place.  I  repeat,  in  all  such  cases,  give  sulphate  of  morphia  in 
sufficient  doses  to  relieve  pain.  If  the  knee-joint  be  injured,  it  should 
be  regarded  as  exceedingly  serious,  in  consequence  of  the  size  and  im- 
portance of  the  articulation.  When  the  inflammation  of  the  synovial 
membrane  is  not  violent,  it  may  result  in  the  eifusion  of  serum,  or 
dropsy  of  the  joint,  and  may  be  aggravated  by  exposure,  violent  ex- 
ercise, or  excess  either  in  eating  or  drinking.  In  such  cases  exercise 
should  be  prohibited,  and  blisters  should  be  applied  alternately  to 
each  side  of  the  knee  once  a  week.  Should  the  patient  be  scrofulous, 
the  iodide  of  potash  and  the  fluid  extract  of  stillingia  should  be  ad- 
ministered until  the  general  health  is  improved. 

Enlargement  of  the  knee-joint  frequently  results  from  rheumatic 
inflammation,  of  which  I  have  already  spoken.  You  should  always, 
when  the  synovial  membrane  is  inflamed,  move  the  joint  occasion- 
ally, otherwise  it  will  become  anchylosed,  and  its  usefulness  be  de- 
stroyed. Sometimes  the  synovial  membrane  becomes  either  thickened 
and  ulcerated  or  entirely  destroyed,  and  then,  when  the  denuded 
ends  of  the  bones  come  or  are  placed  in  contact,  anchylosis  may  take 
place  and  give  the  patient  a  useful  limb,  provided  the  anchylosis 
occurred  when  the  limb  is  in  the  best  position.  Occasionally,  how- 
ever, it  is  impossible  to  obtain  this  result,  and  then  the  only  altern- 
ative is  amputation.  Should  disorganization  extend  beyond  the 
articulating  surfaces,  resection  of  the  articulation  should  be  per- 
formed, and  the  case  treated  as  described  in  the  cases  presented  to 
the  State  Medical  Society  of  California. 

The  next  subject  to  which  I  will  direct  your  attention  is  the  ex- 
istence of  movable  cartilages  in  the  knee-joint.  This  singular  dis- 
ease fortunately  occurs  very  rarely ;  it  cannot  be  cured  without  an 
operation.  When  I  had  charge  of  the  United  States  Hospital,  in 
1854,  there  was  a  case  in  that  institution  which  had  been  allowed  to 
remain  two  years  and  a  half,  in  consequence  of  the  surgeon  in  charge 
not  being  disposed,  or  not  feeling  that  he  was  competent,  to  remove 
a  foreign  body  from  the  joint.  Sometimes  the  patient  could  walk 


LECTURE    XXX.  —  LOOSE    CARTILAGES. 


329 


as  well  as  any  one  in  the  hospital,  but  when  the  cartilage  slipped 
between  the  articulating  surfaces  he  would  become  helpless  and  fall, 
provided  he  could  not  take  hold  of  somebody  or  something,  until  by 
moving  the  joint  the  cartilage  was  displaced  and  the  difficulty  re- 
moved. Being-unwilling  that  a  curable  case  should  remain  longer 
as  a  burden  upon  the  government,  I  determined  to  remove  the  diffi- 
culty. I  had  the  cartilage  forced  up  as  far  as  possible  upon  the 
inner  side  of  the  patella,  and  fixed  in  that  position  by  the  thumbs  of 
a  strong  assistant.  A  valvular  incision  was  made,  and  the  foreign 
body  removed.  The  wound  was  then  closed  by  the  interrupted  silk 
suture,  simple  cerate  with  a  compress  was  applied  and  secured  by  a 
bandage.  The  extremity  was  then  placed  upon  a  splint,  and  retained 
in  that  position  until  the  wound  was  entirely  healed. 

You  must  be  exceedingly  careful,  in  such  cases,  not  to  produce 
ulceration  of  the  skin  by  applying  a  tight  bandage  over  the  com- 
press, for  should  that  occur  the  operation  would  not  only  fail,  but 
the  exposure  of  the  articulating  surfaces  might  produce  sufficient 


FIG.  70. 


inflammation  not  only  to  destroy  the  joint  but  also  the  limb.  These 
operations  require  great  care.  I  have  operated  five  times  with  suc- 
cess, twice  since  these  lectures  were  delivered.  Two  of  the  cartilages 
removed  are  represented  by  the  wood-cut;  the  other  three  oper- 
ations were  performed  at  the  County  Hospital,  before  the  class,  and 
were  as  successful.  To-day,  August  23d,  1876, 1  discharged  an  old 
man  from  the  hospital,  who  had  a  floating  cartilage  removed  three 


330  LECTURES    ON    PRACTICAL    SURGERY. 

weeks  since.     It  was  very  small,  and  he  has  not  suffered  any  incon- 
venience from  the  operation. 

After  the  cartilage  is  removed,  as  some  of  the  synovial  fluid  fol- 
lows its  removal,  before  closing  the  wound  remove  by  pressure  and 
a  wet  sponge  everything  that  may  intervene  that  could  prevent  union 
by  the  first  intention.  A  gentleman  from  Napa  applied  to  me  for 
advice  who  had  more  than  a  dozen  cartilages  in  the  knee-joint,  which 
were  exceedingly  troublesome.  I  told  him  that  I  would  not  per- 
suade him  to  have  an  operation  performed,  but  if  he  should  request 
me  to  operate,  and  if  he  would  take  the  responsibility,  I  would  not 
hesitate,  because  I  believed  that  it  would  be  successful.  In  this  case 
I  think  the  trouble  was  due  to  an  injury  from  a  fall  upon  the  knees. 
The  sailor  fell  through  a  hatchway.  The  other  two  fell  some  dis- 
tance down  a  shaft  in  the  mountains  of  California,  and  supposed 
they  had  entirely  recovered,* when  this  lesion  showed  itself. 

When  any  important  joint  of  the  body  becomes  painful,  and  is 
swollen  without  any  discoloration  of  the  skin,  the  affection  is  called 
a  white  swelling,  and  may  be  located  in  the  synovial  membrane  of 
the  joint,  the  periosteum,  or  the  cancellated  structure  of  the  bone. 
In  the  latter  case  it  is  generally  produced  by  the  deposition  of  tuber- 
culous matter.  These  cases  are  all  of  a  scrofulous  character,  and 
require  tonics,  stimulants,  and  generous  diet.  If  an  abscess  forms, 
an  incision  should  be  made.  If  the  disorder  affects  the  lower  ex- 
tremity, it  should  be  somewhat  flexed  to  render  it  useful.  A  splint 
should  be  applied,  and  the  knee-joint  kept  still  until  anchylosis  re- 
sults. If  the  periosteum  is  affected,  the  carious  bone  should  be 
removed  with  the  trephine,  gouge,  or  chisel,  according  to  the  quantity 
of  the  diseased  bone,  the  part  involved,  as  well  as  the  locality  of  the 
disease. 

In  strumous  children  a  disease  called  gelatinous  degeneration  of 
the  synovial  membrane  takes  place,  as  well  as  of  the  cartilages  of 
the  joint.  They  present  a  grayish-yellow  gelatinous  mass,  which 
varies  from  a  line  to  half  an  inch  in  thickness.  Sometimes  they 
are  absorbed,  but  more  frequently  suppuration  takes  place.  As  soon 
as  fluctuation  is  decidedly  perceived,  an  incision  should  be  made  to 
allow  the  secretion  to  escape,  then  you  have  a  condition  precisely 
similar  to  the  one  already  described.  The  only  alternative  left  is  to 
produce  anchylosis.  Place  the  extremities  of  the  bones  in  contact, 
and  keep  them  in  that  position  for  eight  or  ten  weeks,  when,  if  it 


LECTURE    XXX.  —  MORBUS    COXARIUS.  331 

is  found  to  be  impossible  to  produce  anchylosis,  and  the  local  disease 
continues,  you  may  propose  either  amputation  or  resection ;  the  latter 
is  preferable. 

In  all  scrofulous  affections,  when  all  the  diseased  bone  can  be  re- 
moved, constitutional  treatment  is  of  the  greatest  importance.  To 
children  I  often  give  half  a  grain  of  calomel  at  night  for  a  week, 
for  the  purpose  of  acting  upon  the  stomach  and  liver,  and  when  they 
become  healthy  a  tonic  and  alterative  treatment  should  be  prescribed, 
such  as  sulphate  of  quinine,  with  a  laxative ;  or  the  tonic  mixture, 
composed  of  senna,  nux  vomica,  aconite,  and  hydrocyanic  acid,  which 
I  regard  as  the  best  combination  of  remedies  which  I  have  ever  pre- 
scribed. The  recipe  for  its  preparation  I  have  already  given.  When 
iron  is  indicated,  give  the  precipitated  carbonate,  the  iron  by  hydro- 
gen, or  the  iodide  of  iron.  You  should  not  rely  too  much  upon  iron 
alone,  but  give  with  it  laxatives,  such  as  rhubarb  or  senna ;  the  latter 
acts  upon  the  liver,  and  should  be  preferred. 

There  is  another  disease  of  the  joints  which  I  propose  to  treat 
separately,  in  consequence  of  its  frequency  and  importance  Mor- 
bus  coxarius,  or,  as  it  is  usually  called,  hip  disease,  prevails  in  cold 
damp  climates,  and  hence  occurs  frequently  in  San  Francisco.  It 
affects  children  between  the  ages  of  one  and  four  years,  yet  it  is  not 
confined  to  any  age,  as  I  treated  a  man  about  fifty,  who  subsequently 
died  in  St.  Mary's  Hospital,  after  the  operation  of  resection  was 
performed  by  one  of  the  visiting  physicians  of  that  institution.  I 
have,  in  this  city,  met  with  children  who  had  dislocation  of  the 
hip-joint  from  this  disease  before  they  were  three  years  old.  For- 
merly it  was  believed  that  the  disease  commenced  in  the  acetabulum, 
that  the  cavity  became  filled  by  the  diseased  synovial  membrane, 
the  round  ligament  was  destroyed  by  ulceration,  and  the  head  of  the 
thigh-bone  was  dislodged  or  dislocated,  and  then  the  limb  is  perma- 
nently shortened,  and  the  patient  is  exceedingly  fortunate  if  an  ab- 
scess does  not  form  in  consequence  of  the  existence  of  diseased  bone 
which  no  healthy  tissue  will  accommodate.  This  disease  generally 
commences  in  the  bone,  and  ultimately  the  synovial  membrane  be- 
comes implicated.  The  cartilage  by  which  the  bone  is  covered 
inflames,  ulcerates,  and  sometimes  is  entirely  destroyed,  so  that  it 
cannot  remain  in  its  natural  position,  and  the  bone  becomes  dislo- 
cated. 

Symptoms. — The  patient  almost  always  complains  of  pain  in  the 


332  LECTURES    ON    PRACTICAL    SURGERY. 

knee  or  the  posterior  part  of  the  leg,  slight  lameness  exists,  and 
pressure  made  over  the  head  of  the  thigh-bone  by  the  thumb  and 
fingers  generally  causes  considerable  pain.  The  hip  shrinks  in  con- 
sequence of  the  inactivity  of  the  gluteal  muscles,  produced  by  the 
indisposition  and  inability  of  the  patient  to  take  active  exercise. 
The  appetite  is  often  impaired,  and  if,  with  the  symptoms  enumer- 
ated above,  a  scrofulous  diathesis  exists,  you  should  treat  the  patient 
for  hip  disease.  In  other  words,  prescribe  such  food  as  will  make 
bone  and  brain.  Give  quinine,  combined  with  the  fluid  extract  of 
senna,  have  Sayre's  modification  of  Davis's  splint  applied,  give  the 
patient  a  pair  of  crutches,  encourage  him  to  take  as  much  exercise 
as  he  desires,  and  you  will  succeed  in  arresting  the  disease  and  pre- 
venting the  dreadful  consequences  that  ordinarily  result  from  this 
aifection.  Sometimes  a  child  is  brought  to  my  office,  and  complains 
of  pain  in  the  hip-joint ;  slight  lameness  exists,  which  often  results 
from  rheumatism  or  from  a  fall.  When  they  complain  of  the  hip, 
I  generally  prescribe  my  anti-rheumatic  mixture,  with  the  turpentine 
mixture,  which  I  think  is  the  best  anodyne  liniment  that  can  be 
applied.  3^. — Ol.  terebinth.,  Sivss.;  tinct.  aconit.  rad.,  chloro- 
form, aa  5vj  ;  gum  camph.,  5iij.  M,  Sig.  Apply  5vj,  and  rub  in 
well.  When  the  pain  is  produced  by  injury  or  cold,  the  difficulty 
generally  speedily  disappears,  but  I  am  sorry  that  I  cannot  promise 
the  same  result  in  inorbus  coxarius  when  the  same  treatment  is 
adopted. 

About  twenty  years  since  I  was  called  to  see  the  son  of  Mr.  Wal- 
ton, who  was  the  proprietor  of  the  Fremont  House  in  this  city. 
His  son  was  lame,  and  his  physician  had  treated  him  for  rheuma- 
tism for  several  months,  without  the  slightest  benefit.  After  the 
consultation,  they  refused  to  submit  to  the  treatment  which  I  pre- 
scribed. The  boy  finally  had  a  dislocation  of  the  hip-joint,  and  is 
now  a  resident  of  Sacramento.  Dr.  Cooper  was  employed  after  I 
withdrew,  and  he  applied  a  splint  made  of  tin.  It  was  very  heavy, 
and  one  day  after  the  boy  had  worn  it  for  some  time  he  fell  down- 
stairs, and  the  hip-joint  was  dislocated,  and  young  Walton  was  ren- 
dered a  permanent  cripple.  When  a  patient  has  hip  disease,  he  often 
lingers  one,  two,  or  even  three  years,  and  then  by  accidentally  falling 
sustains  a  dislocation  of  the  hip-joint,  which  produces  permanent 
deformity. 

The  head  of  the  bone  in  such  cases  is  dislocated  upward  and  back- 


LECTURE    XXX.  —  MORBUS    COXARIUS.  333 

ward  ;  the  toes  are  turned  inward,  and  the  limb  permanently  short- 
ened. But  this  is  not  the  most  serious  difficulty  that  may  result  in 
such  cases.  Very  frequently  you  will  find  after  the  dislocation,  and 
sometimes  before,  that  an  abscess  will  form,  and  presents  directly 
over  the  hip-joint.  This  may  result  from  disease  either  of  the  ace- 
tabulum  or  of  the  head  of  the  thigh-bone.  In  children  there  may 
be,  even  after  the  formation  of  an  abscess,  some  prospect  of  recovery. 
The  diseased  bone  sometimes  becomes  detached,  and  escapes  through 
the  external  opening,  and  the  abscess  may  heal ;  but  in  advanced 
life  I  think  it  always  terminates  fatally.  It  is  always  best  to  treat 
a  case  of  this  kind  in  such  a  manner  as  to  prevent  any  such  diffi- 
culty. 

Whenever  the  diagnosis  is  made  out  by  the  existence  of  pain  in  the 
knee  and  posterior  part  of  the  leg,  the  extremity  being  slightly  elon- 
gated, and  the  hip  flattened,  particularly  when  the  hip-joint  is  pain- 
ful on  pressure,  you  should  treat  the  case  as  before  indicated.  Tonics, 
alteratives  with  nutritious  diet,  counterirritation,  with  the  mechanical 
means  recommended,  with  an  instrument  adapted  to  keep  the  artic- 
ulating surfaces  from  coming  in  contact,  so  that  exercise  will  not 
increase  the  local  difficulty.  The  patient  should  take  exercise  every 
day  with  crutches,  which  improves  digestion  and  prevents  the  waste 
which  would  otherwise  occur.  In  the  application  of  this  apparatus, 
great  care  should  be  taken  not  to  make  too  much  extension  and 
counterextension.  I  had  a  case  a  few  years  ago  in  this  city  in  which 
I  felt  great  interest,  in  consequence  of  the  parents  having  lost  a  son 
from  the  same  disease,  by  being  confined  to  bed  until  he  died  from 
exhaustion.  In  the  second  case  I  had  Sayre's  modification  of  Davis's 
splint  applied ;  he  was  allowed  to  take  as  much  exercise  as  he  desired, 
and  was  so  well  when  the  specialist  arrived  in  San  Francisco,  that 
he  said  to  the  parents  that  it  was  one  of  the  best-managed  cases  that 
he  had  seen,  and  that  he  would  insure  a  cure  for  five  dollars.  He 
applied  the  same  instrument  that  I  had  used  for  more  than  a  year 
so  tight,  that  I  said  to  Mr.  Folkers  that  I  did  not  approve  of  so 
much  force  being  used,  and  I  thought  very  unpleasant  consequences 
would  result.  He  also  recommended  that  a  weight  of  ten  or  fifteen 
pounds  should  be  attached  to  the  foot  when  the  boy  was  in  bed. 
The  next  day  the  boy  was  attacked  with  inflammation  of  the  hip- 
joint,  an  abscess  formed,  and  I  opened  it.  Since  then  there  has  been 
a  constant  discharge  from  the  part,  and  it  is  scarcely  possible  that  he 


334 


LECTURES    ON    PRACTICAL    SURGERY. 


should  survive.  Now  I  am  censured  by  the  friends  for  having  con- 
sented to  the  consultation  from  which  resulted  the  present  miserable 
condition  of  a  strong  healthy  boy.  I  did  not  ask  for  a  consultation, 
and  under  the  circumstances  I  could  not  refuse  one,  but  I  must  say 
that  I  did  not  admire  the  man  with  whom  I  consulted,  and  I  pre- 
dicted the  result. 

Resections  of  the  hip-joint  present  no  difficulty  in  the  execution. 
I  have  performed  the  operation  myself  three  times,  but  have  not 


FIG.  71. 


been  satisfied  with  the  result,  and  I  do  not  think  that  I  could  under 
ordinary  circumstances  be  induced  to  repeat  it.  In  children  the 
limb  may  be  saved ;  but  it  is  attached  to  the  pelvis  by  the  muscles, 


LECTURE    XXX.  —  MORBUS    COXARIUS. 


335 


and  is  nothing  better  than  a  dangling  mass  of  bones  and  flesh,  which 
is  an  incurnbrance  of  the  most  serious  character.  Recently  I  have 
resected  the  femur;  the  details  and  results  I  will  give  elsewhere. 


FIG.  72. 


Amputation  of  the  hip  is  much  better  than  resection.  When  the 
head  of  the  thigh-bone  is  exposed,  there  frequently,  and  indeed 
almost  universally,  exists  caries  of  the  acetabulum,  which  it  becomes 
necessary  to  remove.  This  of  course  destroys  the  articulating  stir- 


336  LECTURES    ON    PRACTICAL    SURGERY. 

faces,  and  consequently  the  use  of  the  lower  extremity.  The  re- 
section of  the  elbow  and  ankle-joint  I  have  considered  and  demon- 
strated, and  it  is  not  necessary  to  detain  you  with  a  reconsideration 
of  these  operations.  I  have  resected  the  bones  of  the  wrist,  but  this 
is  not  generally  considered  as  a  very  desirable  operation  ;  you  cannot 
calculate  on  much  subsequent  motion  of  the  joint,  and  when  the 
tendons  are  implicated  very  little  motion  of  the  fingers  should  be 
expected. 


LECTURE    XXXI.  —  INJURIES    OF    MUSCLES.  337 


LECTURE    XXXI. 


IK  my  last  lecture,  on  diseases  of  the  joints,  I  neglected  to  notice 
an  affection  peculiar  to  young  females.  It  is  regarded  as  a  nervous 
or  hysterical  affection  of  the  joints.  It  resembles  rheumatism  more 
than  any  disease,  except  that,  it  is  unaccompanied  by  fever,  and  the 
pain  is  not  increased  by  exercise.  It  occurs  usually  between  the 
ages  of  sixteen  and  twenty,  and  attacks  those  who  otherwise  do  not 
enjoy  good  health,  and  are  generally  unwilling  to  take  active  exercise. 
The  feet  and  legs  usually  swell.  In  such  cases  give  the  precipitated 
carbonate  of  iron,  or  iodide  of  iron,  with  laxatives,  as  previously 
recommended,  and  very  soon  the  swelling  and  pain  will  disappear. 

Muscles  are  liable  to  injuries,  but  not  to  disease.  When  a  muscle 
is  wounded  in  the  direction  of  its  fibres,  no  difficulty  will  be  expe- 
rienced in  effecting  a  union.  Approximate  the  fibres,  keep  the  part 
at  rest,  provide  for  drainage,  and  union  will  take  place  as  rapidly  as 
it  would  if  other  tissues  were  injured.  When  the  wound  is  very 
deep,  unless  the  sutures  are  passed  to  the  bottom,  it  sometimes  be- 
comes necessary  to  apply  a  compress  on  each  side,  and  secure  them 
by  a  roller,  or,  if  preferred,  by  a  many-tailed  bandage.  Sometimes 
the  fibres  of  the  muscles  are  lacerated  by  excessive  action,  and  when 
they  are  not  really  lacerated  they,  from  overaction  or  distension,  lose 
their  contractile  power;  it  is  thus  the  abdomen  becomes  pendulous. 
There  is  one  muscle  which  is  sometimes  dislocated,  viz.,  the  latissi- 
mus  dorsi,  when  it  passes  over  the  inferior  angle  of  the  scapula.  It 
is  intended  to  keep  that  bone  in  its  proper  position,  or  rather  to  aid 
the  subscapularis  in  performing  that  office.  In  such  cases  the  scapula 
becomes  very  prominent,  and  there  is  some  loss  of  use  of  the  arm. 
There  was  one  case  of  this  kind  in  the  County  Hospital  last  summer, 
to  which  I  directed  the  attention  of  the  class.  Physicians  should 
know  that  such  difficulties  do  occur,  although  nothing  can  be  done 
that  will  either  remove  or  alleviate  the  deformity. 

Malignant  tumors,  developed  in  the  adjacent  tissues,  may  implicate 
the  muscles,  but  they  rarely  appear  primarily  in  the  muscular  tissue. 

22 


338  LECTURES    ON    PRACTICAL    SURGERY. 

The  muscles  sometimes  become  paralyzed  and  atrophied  by  want  of 
nervous  influence.  Scriveners'  palsy  is  produced  by  laying  the  arm 
upon  the  writing  table.  Dairymen  often  have  paralysis  of  the  hands 
from  milking,  and  seamstresses  from  sewing  too  constantly.  I  my- 
self had  paralysis  of  the  right  arm  from  driving  a  horse  that  pulled 
'very  hard  upon  the  bit,  and  nearly  two  years  were  required  before  I 
•recovered  the  use  of  the  hand,  and  if  I  had  not  been  subjected  to 
that  misfortune  I  should  now  most  probably  have  been  a  pauper  in 
;my  native  State,  as  almost  all  are  who  occupied  the  position  which  I 
did  when  I  emigrated. 

Partial  paralysis  of  the  face  may  occur  at  any  age,  and  is  always 
preceded  by  pain  in  the  vicinity  of  the  ear.  Sometimes  a  discharge 
exists,  and  when  the  paralysis  results  from  sanguineous  effusion  noth- 
ing will  afford  permanent  relief.  This  difficulty  frequently  results 
from  secondary  syphilis.  I  have  recently  treated  three  boys  who 
were  thus  affected.  The  paralysis  occurred  after  great  suffering,  and 
might  have  been  prevented  by  proper  attention.  Paralysis  always 
results  from  pressure,  which  may  be  produced  by  a  thickening  of 
the  tissues  covering  the  part,  or  from  the  effusion  of  either  blood  or 
serum.  When  it  is  due  to  the  extravasation  of  blood  it  is  incurable, 
but  serum  may  be  absorbed,  and  when  the  cause  is  removed  the  effect 
will  of  course  disappear. 

Tendons  are  as  liable  as  any  other  tissues  of  the  body  to  be  injured. 
Sometimes  they  are  ruptured  by  the  action  of  the  muscle  for  which 
they  form  an  attachment.  The  action  of  the  gastrocnemii  muscles 
frequently  ruptures  the  tendo  Achillis.  When  I  was  a  mill-boy  I 
witnessed  an  occurrence  of  this  character.  A  man,  whilst  carrying 
a  bag  of  corn  up  an  inclined  plane,  fell  just  at  the  door  of  the  mill, 
and  when  a  physician  arrived  it  was  ascertained  that  the  tendo 
Achillis  was  ruptured.  I  was  very  young  at  the  time,  and  do  not 
know  what  was  the  result  of  the  injury.  Five  or  six  years  since  a 
San  Franciscan,  who  had  been  on  a  visit  to  the  East,  had  that  tendon 
accidentally  divided  by  a  piece  of  crockery  ware.  The  physician  of 
the  ship  used  adhesive  plaster  to  close  the  wound,  which  was  passed 
transversely,  by  which  the  skin  was  pressed  down  between  the  ends 
of  the  tendon,  and  prevented  union.  When  he  returned  I  dissected 
the  skin  from  the  space  between  the  ends  of  the  tendon,  the  extrem- 
ities of  which  were  removed  and  placed  in  contact,  and  retained  by 
extending  the  foot.  The  external  wound  was  closed  by  silver  sutures, 


LECTURE    XXXI. — BORS.E.  339 

and  at  the  expiration  of  three  weeks  the  tendon  was  united,  and  he 
lived  in  this  city  for  several  years,  and  finally  died  in  the  St.  Mary's 
Hospital,  of  paralysis  produced  by  specific  disease. 

Sometimes  the  tendons  of  the  fingers  are  ruptured  by  pulling  on 
a  tight  boot.  In  such  cases  the  finger  should  be  flexed,  and  kept  in 
that  position  until  union  takes  place.  A  few  years  since  a  man  named 
Mulligan,  who  was  generally  known  in  this  State,  broke  the  tendon 
of  the  forefinger  of  the  right  hand,  which  I  treated.  The  tendon 
united  in  two  weeks,  and  the  finger  was  as  strong  as  before  the  acci- 
dent. Tendons  unite  very  rapidly,  and  generally  in  ten  days  after 
the  operation  of  tenotomy  they  are  united,  provided  the  extremities 
are  not  separated  more  than  two  inches  and  a  half.  Tendons  are 
said  to  inflame  very  readily,  and  also  to  lose  their  vitality  more  rap- 
idly than  any  other  portion  of  the  body.  The  adjacent  parts  become 
inflamed,  the  congested  vessels  cease  to  convey  blood,  and  the  tendon 
being  deprived  of  its  nutrition  loses  its  vitality.  Tumors  often 
appear  upon  the  tendons,  and  are  produced  by  the  sheath  being  either 
lacerated  or  distended,  which  allows  the  lubricating  fluid  to  escape 
into  a  sac;  this  is  called  a  ganglion.  Formerly  such  swellings 
were  removed.  I  performed  the  operation  once,  but  was  not  satisfied 
with  the  result.  I  then  endeavored  to  lacerate  the  envelope,  and 
force  the  contents  into  the  subcutaneous  cellular  tissue,  and  by  pres- 
sure obliterate  the  cavity.  Not  being  satisfied  with  this  proceeding, 
I  now  open  the  sac  subcutaneously  with  a  tenotomy  knife,  press  the 
contents  into  the  subcutaneous  cellular  tissue,  and  then  apply  a  com- 
press, and  secure  it  by  adhesive  plaster.  It  is  not  safe  to  rely  upon 
a  bandage  in  such  cases,  and  indeed  in  any  case  in  which  it  is  neces- 
sary to  continue  the  pressure  for  two  or  three  weeks,  in  order  to  effect 
a  permanent  cure. 

There  is  another  very  common  disease  which  is  not  very  well 
understood.  It  is  located  in  the  bursse  mucosse  of  the  joints,  and 
affects  the  sheaths  of  tendons,  particularly  of  the  large  extensor  mus- 
cles of  the  thigh.  It  may  be  either  rheumatic  or  syphilitic,  and  I 
must  say  that  it  has  annoyed  me  more  than  any  other  disease  that  I 
have  ever  been  compelled  to  treat,  except  peritoneal  hernia.  I  prac- 
ticed surgery  more  than  twenty  years  before  I  became  fully  satisfied 
that  the  tumors  which  appear  in  the  linea  alba  are  produced  by  an 
escape  of  the  peritoneum  through  a  very  small  opening,  and  still 
longer  to  ascertain  the  true  character  of  the  enlargement  that  some- 


3±0  LECTURES    ON    PRACTICAL    SURGERY. 

times  appears  above  the  knee  joint,  and  frequently  becomes  very 
large  and  troublesome.  In  1854,  when  I  had  charge  of  the  United 
States  Marine  Hospital,  I  was  treating  a  patient  on  Nelson  Street, 
who  was  suffering  from  syphilitic  rheumatism  with  a  distension  of 
the  sheaths  of  the  extensor  tendons.  I  removed  the  fluid  with  a 
trocar  and  canula,  and  injected  into  the  cavity  equal  parts  of  the 
compound  tincture  of  iodine  and  water.  It  was  allowed  to  remain 
five  minutes,  and  then  permitted  to  escape.  In  two  weeks  the  knee 
was  entirely  well,  and  I  operated  upon  the  other.  After  the  removal 
of  the  solution  of  iodine,  the  lower  portion  of  the  thigh  became  very 
much  inflamed,,  suppuration  took  place,  and  so  soon  as  it  occurred  I 
made  an  incision,  and  gave  him  a  bottle  of  porter  every  day.  He 
recovered  entirely  by  this  constitutional  and  local  treatment. 

The  bursse  very  often  become  greatly  enlarged,  particularly  the 
bursse  of  the  patella  and  olecranon  process  of  the  ulna.  The  former 
generally  results  from  throwing  the  weight  of  the  body  upon  the 
knees  when  scrubbing  the  floor,  and  the  latter  by  striking  the  olec- 
ranon process  against  some  solid  body.  Generally  the  enlargements 
can  be  removed  by  painting  them  well,  morning  and  evening,  with 
equal  parts  of  tinct.  iodine  and  arnica.  Should  this  treatment  fail, 
you  may  either  draw  the  fluid  off  with  a  trocar  and  canula,  and  inject 
the  sac  with  the  compound  tinct.  of  iodine  and  water,  or  make  an 
incision,  insert  a  tent,  and  keep  the  wound  open  until  it  heals  from 
the  bottom,  or  in  other  words  until  the  cavity  is  obliterated.  I  will 
refer  to  this  subject  again,  when  specific  diseases  are  under  consider- 
ation. They  are  the  most  prolific  source  of  this  difficulty,  particu- 
larly near  the  knee-joint. 

Wounds  of  the  Throat. — I  will  now  say  a  few  words  about  wounds 
of  the  throat,  which,  like  all  other  solutions  of  continuity,  are  either 
punctured,  incised,  or  contused.  They  are  generally  incised  and 
transverse,  and  are  almost  always  near  the  os  hyoides,  sometimes 
above  that  bone,  but  more  frequently  below.  Always  ascertain,  if 
possible,  the  location  of  the  wound.  When  deep,  if  upon  the  upper 
part  of  the  neck,  it  may  extend  into  the  pharynx ;  if  lower  down 
upon  the  neck  the  larynx  is  generally  involved,  but  it  is  very  seldom 
that  the  large  vessels  of  the  neck  are  wounded.  These  wounds  are 
generally  made  by  a  razorr,for  the  purpose  of  committing  suicide, 
the  subjects  being  tired  of  life.  They  seldom  succeed,  not  more 
than  one  in  twenty  cases,, because  they  draw  the  instrument  trans- 


LECTURE    XXXI.  —  INJURIES    OF    THE    NECK.  341 

versely  across  the  throat.  Suicides  generally  become  alarmed  by  the 
appearance  of  the  blood,  and  desist  before  their  object  is  accom- 
plished. 

It  is  important  in  such  cases  to  ascertain  at  once  whether  the  inci- 
sion is  above  or  below  the  rima  glottidis.  If  above,  the  blood  may 
pass  into  the  larynx  and  produce  suffocation.  In  cases  of  this  char- 
acter, you  must  ascertain  whether  the  larynx,  trachea,  or  pharynx  be 
wounded  ;  if  the  latter,  it  is  important  to  turn  the  patient  upon 
the  face,  take  hold  of  the  edges  of  the  wound  with  the  finger  and 
thumb,  and  press  them  together,  the  patient  being  upon  the  face, 
and  being  kept  in  that  position  with  the  wound  firmly  closed  until 
the  haemorrhage  has  entirely  ceased.  This  position  is  of  importance, 
in  order  that  the  blood  may  flow  externally  and  not  into  the  larynx. 
Should  the  artery  be  divided,  death  would  occur  before  any  assistance 
could  be  obtained.  Haemorrhage  from  the  internal  jugular  vein  can 
be  arrested  by  the  pressure  made  by  means  of  a  small  portion  of 
sponge,  which  should  be  allowed  to  remain  six  or  seven  days,  and 
when  removed  not  the  slighest  hemorrhage  will  follow.  I  was  per- 
forming an  operation  upon  the  neck,  and  wished  to  expose  the  com- 
mon carotid;  the  external  incision  I  thought  was  too  small,  and  en- 
larged it  with  a  pair  of  scissors,  I  now  think  carelessly,  and  either 
the  internal  jugular  or  the  superior  thyroid  was  wounded.  A  small 
piece  of  sponge  was  applied,  and  retained  in  contact  with  the  wounded 
vein  until  the  ligature  was  applied  to  the  carotid,  when  a  suture  was 
passed  through  the  edges  of  the  wound  directly  over  the  sponge.  It 
was  allowed  to  remain  seven  days,  and  when  removed  the  wound  in 
the  vein  was  closed,  and  the  patient  recovered  as  rapidly  as  if  no 
accident  had  occurred.  In  applying  a  ligature  upon  the  carotid, 
great  care  should  be  taken  not  to  wound  the  internal  jugular  vein. 
It  is  on  the  outer  side  of  the  artery,  and  low  down  on  the  neck  it  is 
very  large,  and  lies  over  the  artery  so  as  to  conceal  it  entirely,  hence 
great  care  is  required  not  to  wound  it  whilst  ligating  the  common 
carotid. 

When  the  pharynx  is  wounded,  the  injury  is  much  more  serious 
than  if  you  have  simply  a  wound  of  the  larynx.  In  a  case  of  that 
character,  the  patient  should  be  fed  through  a  tube  passed  into  the 
oesophagus,  and  the  nutriment  thrown  by  a  syringe  into  the  stomach 
in  sufficient  quantities  to  supply  the  waste  of  the  body.  In  that 
way  you  can  sustain  the  patient  until  the  wound  closes.  I  shall 


342  LECTURES    ON    PRACTICAL    SURGERY. 

always  recollect  an  old  man  who  lived  near  my  father's  place,  whose 
name  was  Pease.  He  had  a  disappointment  when  young,  attempted 
suicide,  and  cut  into  the  oesophagus.  Whenever  he  attempted  to 
swallow  a  fluid,  a  portion  escaped  through  an  opening  upon  the 
upper  and  central  part  of  the  neck.  He  was  at  least  seventy-five  or 
eighty  years  old,  lived  entirely  alone,  and  cultivated  land  enough  to 
supply  his  wants.  But  in  consequence  of  this  early  misfortune,  he 
never  associated  even  with  his  nearest  neighbors,  and  never  appeared 
to  recognize  any  of  the  children  when  they  passed  by  his  place  when 
out  hunting.  Wounds  of  the  neck  should  always  be  closed  by  the 
interrupted  silver  suture,  the  points  being  sufficiently  numerous  to 
bring  the  edges  in  perfect  apposition  ;  then  the  warm-water  dressing 
should  be  applied,  and  union  by  the  first  intention  rarely  fails  to 
occur. 

It  sometimes  becomes  necessary  to  make  an  opening  into  the  larynx 
or  trachea,  or  in  other  words  to  perform  the  operation  of  laryngotomy 
or  tracheotomy,  in  order  to  prevent  suffocation,  when  the  respiration 
is  rendered  difficult  either  by  inflammation,  serous  effusion,  or  the 
pressure  of  an  aneurismal  tumor  upon  the  trachea  above  the  upper 
extremity  of  the  sternum.  I  performed  this  operation  once,  but  I 
never  will  perform  it  again  without  ascertaining  the  cause  and  extent 
of  the  difficulty.  In  diphtheria,  I  now  in  every  case  positively  re- 
fuse to  open  the  trachea,  and  in  my  own  practice  I  never  find  a  case 
in  which  an  operation  is  necessary,  except  when  a  foreign  body  finds 
its  way  into  the  respiratory  apparatus. 

Sometimes  in  tonsillitis  or  quinsy,  the  passage  to  the  lungs  is  so 
contracted  that  the  breathing  becomes  very  difficult,  and  then  instead 
of  opening  either  the  larynx  or  trachea,  expose  the  tonsils.  Make  a 
free  incision  on  each  side,  and  the  difficulty  will  entirely  disappear. 
When  the  respiration  becomes  difficult,  as  in  croup,  the  blood  does 
not  become  oxygenated  in  the  lungs,  and  consequently  does  not  afford 
the  heart  a  sufficient  quantity  of  healthy  blood  to  enable  it  to  con- 
tinue the  performance  of  its  function.  In  nearly  every  case  of  croup 
in  which  operations  are  usually  performed,  you  can  give  relief  by 
the  subcarbonate  of  potash.  Give  to  a  child,  two  or  three  years  old, 
two  grains  of  the  salt  every  two  hours;  the  albumen  which  forms  the 
membrane  is  dissolved,  and  in  many  cases  the  croupy  symptoms  dis- 
appear in  a  few  hours.  If  this  prescription,  which  I  obtained  from 
a  German  medical  journal,  does  not  remove  the  deposit,  it  will  be 


LECTURE    XXXI.  —  TRACHEOTOMY.  343 

necessary  to  operate.  But  when  foreign  bodies  find  their  way  into 
the  trachea,  you  must  make  an  opening,  which  can  be  accomplished 
either  by  dividing  the  crico-thyroid  ligament,  or  two  or  three  of  the 
upper  rings  of  the  trachea ;  or  the  latter  may  be  opened  below  the 
thyroid  gland  and  just  above  the  superior  extremity  of  the  sternum. 
I  witnessed  an  operation  of  this  character,  performed  by  my  former 
partner,  Dr.  William  H.  Wells,  in  Columbia,  South  Carolina,  which 
was  successful.  Before  cutting  into  the  larynx  or  trachea,  divide  the 
skin,  the  subcutaneous  cellular  tissue,  and  the  artery,  a  branch  of 
the  superior  thyroid  that  crosses  the  crico-thyroid.  That  vessel 
should  be  ligated,  and  when  the  haemorrhage  has  been  entirely  ar- 
rested, the  crico-thyroid  ligament  should  be  divided  transversely, 
and  should  any  foreign  body  be  in  the  trachea  it  will,  with  the  first 
expiration,  be  expelled,  and  if  not,  long  delicate  forceps  may  be  in- 
troduced for  the  purpose  of  removing  it. 

Sometimes  it  is  considered  advisable  to  divide  the  upper  rings  of 
the  trachea.  In  such  cases,  the  same  precautions  should  be  taken. 
Any  artery  which  is  divided  should  be  ligated,  and  the  trachea  opened 
freely.  Three  or  four  of  the  rings  may  be  divided  without  the  pos- 
sibility of  any  serious  difficulty  occurring.  Both  of  the  operations 
recommended  are  perfectly  safe,  if  carefully  performed.  I  always 
have  the  skin  raised  by  myself  and  an  assistant,  then  a  perpendicular 
incision  should  be  made,  extending  through  the  skin  and  subcuta- 
neous cellular  tissue,  down  the  larynx  or  trachea.  Should  the  artery 
be  divided,  it  must  be  ligated  before  the  opening  is  made,  either 
through  the  crico-thyroid  ligament  or  the  rings  of  the  trachea.  The 
former  should  be  divided  transversely,  and  the  latter  perpendicularly. 

When  the  superficial  vessel  has  been  ligated,  not  the  slightest  dan- 
ger of  haemorrhage  exists,  as  there  are  no  bloodvessels  in  that  vicinity 
from  which  a  fatal  haemorrhage  could  occur.  So  soon  as  the  opening 
is  made,  and  the  air  rushes  into  the  lungs,  the  patient  is  relieved, 
provided  there  existed  an  obstruction,  and  if  the  operation  was  per- 
formed to  remove  a  foreign  body  from  the  trachea,  it  is  almost  always 
forced  out  by  the  first  expiration.  I  shall  never  forget  a  case  in 
which  a  persimmon  seed  found  its  way  into  the  trachea  of  a  child 
two  or  three  years  old.  The  parents  lived  in  Newbury  Village, 
South  Carolina,  and  I  lived  in  Columbia,  and  was  sent  for  to  per- 
form the  operation.  In  order  to  obtain  a  good  light,  the  door  of  the 
parlor  was  selected,  and  when  the  crico-thyroid  ligament  was  divided, 


344  LECTURES    ON    PRACTICAL    SURGERY. 

the  seed,  covered  with  mucus  and  blood,  escaped  from  the  wound 
and  lodged  upon  the  facing  of  the  door,  which  was  more  than  a 
yard  from  the  patient. 

Should  the  foreign  substance  still  remain,  I  would  advise  you  to 
use  the  long  delicate  forceps  exhibited.  Should  suffocation  be  threat- 
ened, in  consequence  of  a  contraction  of  the  larynx,  then  tracheot- 
omy should  be  performed,  and  an  opening  made  large  enough  to 
admit  the  tube,  by  which  the  patient  is  enabled  to  breathe  until  the 
obstruction  disappears.  I  am  opposed  to  the  instruments  invented 
for  this  operation.  A  lancet  or  bistoury  is  all  that  is  required  to 
divide  the  crico-thyroid  ligament,  and  a  scalpel  should  be  used  to 
complete  the  tracheotomy ;  then  the  usual  instrument  should  be  in- 
serted and  continued  so  long  as  necessary.  Occasionally  when  a 
syphilitic  ulcer  of  the  larynx  heals,  the  size  of  the  larynx  is  very 
materially  diminished,  so  much  so  that  suffocation  must  take  place 
without  an  operation.  About  fifteen  years  ago,  a  gentleman  came  to 
my  office  about  sunrise,  and  begged  me  to  see  a  man  on  the  corner, 
or  near  the  corner,  of  Davis  and  Sacramento  Streets.  His  breathing 
was  so  difficult  that  I  could  hear  him  at  least  a  hundred  yards.  I 
opened  the  larynx  with  my  lancet,  which  afforded  immediate  relief. 
The  ordinary  tube  was  introduced,  which  he  did  not  like.  He  then 
arranged  two  goosequills,  attached  them  to  a  large  tube  which  he 
passed  around  his  neck,  and  covered  it  with  a  comforter.  The  air 
was  thus  compelled  to  pass  through  a  warm  tube  five  or  six  feet 
in  length  before  it  reached  the  lungs,  and  consequently  produced 
much  less  irritation  than  resulted  from  the  ordinary  treatment.  He 
wore  that  apparatus  several  years,  and  returned  to  his  native  country 
comfortable,  but  not  well,  although  the  tertiary  symptoms  had  en- 
tirely disappeared.  Dr.  Stout,  of  this  city,  has  invented  an  instru- 
ment for  the  purpose  of  opening  the  trachea.  I  think  it  is  as  good 
as  any  instrument  that  has  been  recommended  in  such  cases.  I  have 
never  availed  myself  of  the  advantages  presented  by  these  produc- 
tions of  genius,  because  I  could  always  perform  such  an  operation 
with  a  lancet  or  a  pocket-knife,  and  could  remove  the  tonsils  with 
an  ordinary  fish-hook  and  a  jack-knife  with  the  point  broken  off,  so 
as  to  prevent  the  possibility  of  any  serious  result. 

In  conclusion,  allow  me  to  advise  you  never  to  perform  trache- 
otomy or  laryngotomy,  unless  the  responsible  party  is  able  to  pay 
the  bill.  The  man  on  whom  I  operated,  on  Sacramento  Street,  sold 


LECTURE    XXXI. — TRACHEOTOMY.  345 

his  property,  did  not  pay  me  one  cent ;  yet  I  hope  he  is  as  comfort- 
able as  any  man  who  has  a  hole  in  his  trachea  can  be,  when  he  knows 
that  the  man  who  saved  his  life  did  not  receive  one  cent  either  for 
the  operation  or  the  subsequent  attention.  Never  open  either  the 
larynx  or  trachea  in  diphtheria.  I  have  operated  to  gratify  the 
parents,  and  when  the  child  dies  they  say  that  the  doctor  committed 
homicide.  I  have  lived  a  long  time,  have  treated  many  children, 
and  I  beg  of  all  young  practitioners  never  to  perform  tracheotomy 
in  cases  of  diphtheria.  They  always  die,  because  the  false  mem- 
brane has  formed  in  the  lungs,  and  has  destroyed  the  function  of 
these  important  organs. 


L 


H  A  it 


346  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE  XXXII. 

Wounds  of  the  Chest. — The  last  lecture  was  concluded  after  con- 
sidering the  cases  by  which  laryngotomy  and  tracheotomy  are  rendered 
both  necessary  and  proper.  I  think  I  then  told  you  never  to  per- 
form an  operation  upon  the  air-passages  without  a  careful  exam- 
ination, because  I  once  performed  such  an  operation  by  the  request 
of  two  prominent  physicians  of  this  city,  and  at  night,  without 
affording  the  relief  which  they  expected,  because  the  difficulty  of 
respiration  was  produced  by  an  aneurism  of  the  aorta.  Sometimes 
great  difficulty  of  deglutition  may  result  from  aneurism,  but  more 
frequently  it  is  produced  by  stricture,  caused  by  swallowing  either 
nitric  or  sulphuric  acid  by  mistake.  Some  years  since,  a  child,  whose 
parents  lived  on  Ohio  Street,  near  a  soda  factory,  visited  the  place 
and  took  a  drink  from  a  bottle  that  contained  sulphuric  acid,  instead 
of  soda  water,  and  died  of  starvation  in  eight  or  ten  days,  being,  so 
long  as  she  lived,  unable  to  take  anything  into  the  stomach.  I  have 
met  with  other  cases  in  which  stricture  was  produced  by  the  same 
cause.  It  is  very  seldom  that  with  a  bougie  you  can  remove  a 
cicatrix  produced  in  that  manner.  In  ordinary  cases  of  stricture  of 
the  oesophagus,  a  large  gum-elastic  bougie  may  remove  the  tem- 
porary inconvenience  of  a  stricture.  It  should  be  passed  every  al- 
ternate day,  and  allowed  to  remain  fifteen  or  twenty  minutes,  but, 
gentlemen,  I  must  say  that  the  treatment  of  such  cases  is  never 
satisfactory. 

The  next  difficulty  of  a  prominent  character  that  presents  itself 
is  bronchocele,  or,  as  it  is  usually  called,  goitre.  It  presents  three 
varieties:  1.  The  vascular;  2.  The  encysted;  3.  The  calcareous. 
The  first  is  called  vascular  sarcoma,  and  is  simply  an  enlargement 
of  the  thyroid  body,  which  sometimes  increases  to  an  enormous  size. 
It  prevails  in  cold  damp  climates,  as  in  the  mountains  of  Switzer- 
land, Pennsylvania,  and  particularly  in  the  valleys  of  the  Blue 
Ridge  and  Cumberland  Mountains  of  North  Carolina,  as  well  as  the 
northern  portion  of  this  State  and  Oregon.  The  sun  is  excluded 


LECTURE    XXXII.  —  GOITRE.  347 

from  these  coves,  as  they  are  called,  until  ten  or  eleven  o'clock,  and 
never  shines  upon  them  for  more  than  three  or  four  hours,  even 
during  the  summer  months.  In  the  winter  its  genial  rays  scarcely 
ever  bless  them  at  all.  It  was  at  one  time  supposed  that  goitre  was 
produced  by  the  use  of  snow-water,  but  now  it  is  known  that  it  re- 
sults from  the  excessive  humidity  of  the  atmosphere,  in  consequence 
of  the  exclusion  of  the  sun.  Sometimes  a  cyst  forms  in  the  thyroid 
body,  which  is  called  hydrocele  of  the  neck,  and  which  can  only  be 
cured  by  an  operation.  In  such  cases  fluctuation  is  distinct.  The 
character  of  the  tumor  can  be  determined  by  the  exploring  needle, 
and  when  the  presence  of  serum  is  positively  ascertained,  an  incision 
should  be  made,  and  the  wound  kept  open  by  the  introduction  of  a 
tent,  so  that  it  shall  not  heal  until  the  cavity  is  obliterated.  This  is 
always  a  serious  operation,  and  one  that  is  followed  by  great  con- 
stitutional disturbance.  I  am,  however,  from  long  experience,  con- 
vinced that  the  operation  which  I  propose  is  more  safe  than  any 
other,  and  more  successful,  and  indeed  the  only  method  by  which 
the  disease  can  be  cured.  I  have  operated  successfully  four  times, 
once  in  South  Carolina,  and  three  times  in  California.  I  have 
never  lost  a  patient,  although  one  was  told  that  he  should  make  his 
will,  as  death  would  result  from  haemorrhage  so  soon  as  an  incision 
was  made.  This  man  had  taken  two  or  three  pounds  of  iodide  of 
potassium,  had  applied  the  tincture  of  iodine  externally,  and  all 
without  the  slightest  benefit  having  resulted,  and  yet  the  difficulty 
was  removed  without  much  risk,  and  without  either  general  or  local 
treatment,  except  the  operation.  Sometimes  the  thyroid  body  be- 
comes enormously  enlarged,  and  is  so  formidable  in  its  vascular 
proportions  that  few  surgeons  have  felt  that  they  were  justified  in 
endeavoring  to  remove  either  the  thyroid  gland  or  any  portion  of  it. 
It  can  be  distinguished  from  any  other  tumor  upon  the  neck  by  the 
fact  that  it  always  follows  the  movements  of  the  trachea  in  the  act 
of  deglutition.  In  ordinary  cases  of  goitre,  as  has  been  determined 
by  the  experiments  of  Coindet  and  others,  iodide  of  potassium  is 
the  only  remedy  that  will  prove  effectual.  This  article  should  be 
given  internally,  and  the  tincture  of  iodine  and  arnica  applied  ex- 
ternally, morning  and  evening.  The  tincture  of  iodine  alone  is  too 
irritating,  and  consequently  should  be  combined  with  an  equal 
quantity  of  the  tincture  of  arnica ;  two  or  three  coats  should  be 
applied  with  a  camel's-hair  pencil,  at  intervals  of  five  minutes,  until 


348  LECTURES    ON    PRACTICAL    SURGERY. 

severe  irritation  is  produced.  During  the  use  of  this  external  irri- 
tant, give  from  five  to  ten  grains  of  the  iodide  of  potassium  three 
times  a  day,  either  with  syrup,  the  fluid  extract  of  stillingia,  or  the 
syr.  of  sarsaparilla,  according  to  the  judgment  of  the  practitioner 
and  the  taste  of  the  patient,  which  we  are  often  obliged  to  consult, 
even  in  cases  in  which  much  more  depends  upon  the  virtue  than 
upon  the  taste  of  the  medicine.  Sometimes  when  the  thyroid  body 
becomes  enlarged,  its  substance  loses  its  vascularity  and  softness,  in 
other  words,  the  body  of  the  thyroid  gland  on  one  side  becomes 
solid,  and  presses  so  much  upon  the  trachea  that  respiration  becomes 
difficult,  and  an  operation  is  necessary  in  order  to  prevent  suffoca- 
tion, which  is  otherwise  unavoidable.  If  you  cannot  remove  a  tumor 
of  this  character  by  internal  and  external  applications,  then  if  suffo- 
cation be  threatened,  it  is  important,  and  indeed  becomes  im- 
perative upon  a  surgeon  to  make  an  effort  to  save  a  human  life, 
even  at  the  expense  of  a  reputation,  and  perhaps  a  tedious  lawsuit. 
There  are  only  a  few  surgeons  who  have  operated,  and  I  cannot  now 
name  those  who  have  operated  successfully  with  the  ligature ;  but 
it  is  the  only  method  by  which  a  tumor  of  this  character  can  be 
removed  successfully.  I  some  years  since  operated  upon  a  case  of  a 
calcareous  enlargement  of  the  right  lobe  of  the  thyroid  gland.  In 
South  Carolina,  in  1835,  I  had  a  case  of  this  character.  At  that 
time  Dr.  Wells  and  I  were  unable  to  determine  the  character  of  the 
difficulty,  although  we  were  fully  aware  of  the  danger  of  such  an 
operation,  and  were  so  unwilling  to  undertake  it,  that  the  friends, 
as  an  inducement,  offered  to  pay  extravagantly  if  we  succeeded.  I 
had  only  left  Paris  a  few  months  before,  and  Dr.  Thomas  Wells 
evidently  did  not  favor  the  operation,  and  I  was  therefore  requested 
to  perform  such  a  one  as  might  be  required.  I  said  to  Dr.  Wells, 
after  I  had  made  a  few  incisions,  that  the  growth  did  not  present 
the  appearance  of  an  ordinary  tumor.  I  then  made  another  incision, 
deep  but  short,  from  which  the  blood  poured  in  a  fearful  stream. 
Dr.  Wells  arrested  the  haemorrhage  with  his  finger  and  thumb,  and 
I  surrounded  the  tumor  by  a  strong  ligature.  The  patient  recovered, 
and  I  am  glad  to  say  that  the  result  added  to  the  reputation  of  both 
Dr.  Wells  and  myself. 

Wounds  of  the  chest,  particularly  superficial  wounds,  do  not 
differ  from  those  on  any  other  portion  of  the  body,  and  whether 
they  be  longitudinal  or  transverse,  provided  they  are  incised,  they 


LECTURE    XXXII. — WOUNDS    OF    THE    CHEST. 


349 


should  be  closed  by  the  interrupted  silver  suture,  and  dressed  so  as 
to  secure  union  by  the  first  intention.  Penetrating  wounds  are  al- 
ways serious,  and  the  principles  of  their  treatment  should  be  well 
understood,  as  no  time  is  allowed  for  preparation.  Whenever  a 
sharp-pointed  or  cutting  instrument  wounds  the  lung  sufficiently  to 
allow  the  air  to  escape  into  the  pleural  cavity,  the  lung  collapses  by 
reason  of  the  external  pressure,  and  consequently  ceases  to  perform 


FIG.  73. 


its  function.  This,  however,  need  not  be  regarded  as  very  serious. 
Close  the  external  wound;  the  air  by  which  the  pleural  cavity  was 
filled  will,  soon  be  absorbed;  the  lung  will  expand,  and  perform  its 
function  just  as  well  as  before  the  receipt  of  the  injury. 

I  repeat  that  whenever  there  is  a  wound  sufficiently  extensive  to 
permit  the  air  to  escape  into  the  pleural  cavity  the  lung  collapses. 
All  that  you  are  required  to  do  is  to  close  the  external  wound,  apply 
a  compress  and  bandage,  and  in  twenty-four  hours  the  air  will  dis- 
appear, and  the  difficulty  be  removed,  provided  the  injury  is  not 
followed  by  pleurisy.  When  the  inflammation  of  the  pleura  is  not 
acute,  the  effusion  of  either  serum  or  pus  may  occur.  The  former 
is  called  hydrothorax  and  the  latter  empyema.  They  produce  the 
same  temporary  difficulty  that  is  experienced  in  emphysema,  al- 
though they  are  both  of  a  much  more  serious  character.  I  claim  to* 


350  LECTURES    ON    PRACTICAL    SURGERY. 

have  been  the  first  to  point  out  the  correct  method  of  treating  such 
cases,  and  I  have  been  successful  by  pursuing  the  course  which  I 
will  now  describe. 

Inflammation  either  of  the  pleura  costalis,  pulmonalis,  or  of  the 
substance  of  the  lungs,  may  produce  a  secretion  of  either  pus  or 
serum ;  the  latter  can  generally  be  relieved  by  counterirritation  and 
diuretics.  Should,  however,  this  course  fail,  and  the  air  still  enter 
the  lung,  or,  in  other  words,  if  the  bronchial  tubes  are  pervious,  the 
fluid  should  be  gradually  drawn  off  with  an  aspirator,  so  as  to  di- 
minish the  pressure  sufficiently  to  favor  the  expansion  of  the  lung. 
A  case  occurred  in  this  city  recently,  in  which  not  the  slightest 
respiratory  murmur  could  be  detected,  on  account  of  an  effusion  of 
serum,  which  was  not  removed.  A  post-mortem  proved  that  the 
lung  was  not  larger  than  a  man's  fist,  and  perfectly  solidified,  not  a 
single  air-tube  being  found  pervious. 

In  1835,  Dr.  McQueen,  of  Sumpterville,  South  Carolina,  placed 
himself  under  the  care  of  Dr.  Wells  and  myself.  He  had  an  ac- 
cumulation of  pus  in  the  right  side  of  the  chest ;  a  large  quantity 
was  discharged  when  the  trocar  was  introduced;  the  entire  con- 
tents of  the  cavity  were  not  allowed  to  escape,  and  then  the  wound 
was  closed  carefully  for  fear  that  the  air  might,  if  admitted,  produce 
serious  consequences.  Being  the  junior  partner,  I  was  required  to 
dress  the  patient  every  morning.  Finally  the  opening  enlarged  by 
ulceration,  and  the  matter  discharged  constantly,  and  contrary  to 
the  expectations  of  both  the  physicians  and  friends,  the  cavity 
cleared  and  the  doctor  regained  his  health.  Recollecting  the  re- 
sult in  this  case,  as  well  as  the  cause,  I  adopted  a  similar  course  of 
treatment  in  the  case  of  Captain  Chase,  who  had  been  in  the  United 
States  Marine  Hospital  for  more  than  two  years,  without  the 
slightest  improvement,  and  without  the  shadow  of  a  hope  of  re- 
covery. The  opening  had  been  made,  through  which  the  pus  escaped 
two  or  three  times  a  week.  By  pursuing  such  a  course  a  cure  was 
impossible,  because  the  cavity  could  not  close  unless  it  was  kept 
empty,  consequently  I  had  a  tube  made,  such  as  is  represented  in 
Fig.  74,  this  being  inserted.  The  stopple  was  removed  every  two 
or  three  hours,  the  cavity  gradually  contracted,  and  the  discharge 
finally  ceased.  The  patient,  when  I  left  the  hospital,  was  the  porter 
of  the  establishment,  and  enjoyed  as  good  health  as  any  man  in  the 
institution.  Watson  said  that  there  was  no  established  method  of 


LECTURE    XXXII.  —  EMPYEMA.  351 

treating  such  a  difficulty.  A  case  was  never  cured  except  by 
accident  until  the  method  described  was  adopted,  which  was  three 
years  before  the  drainage-tube  was  employed  either  in  France  or 

FIG.  74. 


England,  as  I  proved  by  an  article  published  in  the  Pacific 
Medical  Journal,  by  my  nephew,  Dr.  Cameron,  of  Red  Bluff, 
California. 

In  the  case  of  a  man  from  Nevada,  California,  the  ribs  were 
fractured  by  a  pistol-ball  which  entered  near  the  sternum  on  the 
right  side,  passed  through  the  right  chest,  and  escaped  at  the  angle 
of  the  ribs,  by  which  one  was  injured.  When  I  saw  him  there  was 
about  a  gallon  of  pus  in  the  cavity  of  the  right  pleura,  which,  with 
other  foreign  bodies,  was  removed.  The  anterior  portion  of  the 
diseased  rib  was  first  removed,  allowing  the  pus  to  escape.  The  res- 
piratory murmur  was  audible  at  the  upper  portion  of  the  lung.  The 
tube  was  inserted  the  second  day,  and  the  cavity  kept  partially 
empty  for  the  purpose  of  enabling  the  lung  to  expand,  and  the 
cavity  to  close.  On  the  second  day  after  the  operation  some  pieces 
of  cloth  and  one  piece  of  bone  escaped  with  the  pus,  which  would 
without  any  other  cause  have  prevented  the  recovery  of  the  patient. 
By  passing  a  straight  silver  sound  about  a  foot  in  length,  I  detected 
the  diseased  bone  on  the  inside  and  posterior  part  of  the  chest,  and 
succeeded  in  removing  it  without  much  difficulty,  having  waited 
until  the  fever  had  subsided.  The  discharge  greatly  diminished  and 
the  lung  considerably  expanded.  This  operation  was  followed  by 
the  most  satisfactory  result.  The  patient  improved  daily,  and  in 
two  or  three  months  he  obtained  the  situation  of  doorkeeper  at 
Adams's  Museum,  near  the  City  Hall,  and  remained  there  until  he 


352  LECTURES    ON    PRACTICAL    SURGERY. 

had  recovered  sufficiently  to  return  to  his  native  State,  Illinois.  I 
received  a  letter  since,  which  stated  that  he  continued  to  improve, 
and  was  living  with  his  parents,  in  perfect  health.  I  have  operated 
repeatedly  in  cases  of  empyema  resulting  from  pleuritis,  in  gun- 
shot wounds,  and  have  never  failed,  except  in  cases  produced  by  the 
rupture  of  the  cavity  caused  by  the  disintegration  of  tubercles  into 
the  pleural  cavity.  The  result  in  such  cases  has  not  been  so  satis- 
factory as  to  incline  me  to  operate  again.  There  was  one  case  of 
empyema  in  which  the  result  was  so  extraordinary  that  I  will 
mention  it  in  detail.  A  young  man,  who  lived  in  Virginia  City, 
received  a  gunshot  wound,  the  ball  passing  under  the  clavicle  and 
lodging  in  the  right  lung,  about  four  or  five  inches  below  the  point 
of  entrance.  An  abscess  formed,  the  contents  of  which  escaped  about 
every  two  weeks  by  the  mouth.  Having  ascertained  the  extent  of  the 
cavity  by  percussion  and  auscultation,  an  incision  was  made  between 
the  fourth  and  fifth  ribs.  A  trocar  was  passed,  which  fortunately 
entered  the  lower  extremity  of  the  sac,  and  the  contents  escaped 
through  the  opening.  A  tube  was  then  inserted  and  worn  for  four  or 
five  months,  and  indeed  until  he  was  perfectly  cured.  I  met  him  a 
few  years  ago  in  this  city,  and  he  was  enjoying  perfect  health.  I 
operated  upon  another  patient  in  the  same  condition,  as  the  result  of  a 
gunshot  wound  of  the  left  side.  The  cavity  was  opened,  the  tube  was 
inserted  and  retained  until  the  patient  was  entirely  well,  and  he  was 
afterwards  employed  as  a  nurse  in  the  County  Hospital.  The  drain- 
age-tube which  I  employ  was  in  use,  and  the  cases  were  published, 
three  years  before  that  course  of  treatment  was  practiced  or  suggested 
by  any  other  physician,  and  it  is  possible  that  the  Pacific  Medical 
Journal  may  have  found  its  way  both  to  France  and  England. 
Facts  are  simple,  and  after  a  discovery  is  made  we  are  astonished 
that  it  had  not  been  thought  of  before.  Velpeau,  in  his  work  on 
operative  surgery,  did  not  recommend  the  removal  of  the  ribs,  and 
doubted  the  propriety  and  even  the  safety  of  such  operations.  I 
removed  two  ribs  in  the  following  case :  A  man  belonging  to  a 
hunting  party,  encamped  not  far  from  Los  Angeles,  returned  to  the 
camp  at  night  without  giving  the  sign  agreed  upon,  and  one  of  his 
friends  shot  him  with  a  rifle;  two  ribs  were  wounded,  and  the  ball 
passed  between  them,  but  escaped  without  wounding  the  pleura  on 
the  opposite  side  of  the  ckest,  which  is  the  reason  that  it  was  not 


LECTURE    XXXII.  —  EMPHYSEMA.  353 

fatal.  I  have  operated  repeatedly  in  cases  of  this  character,  and 
have  never  had  reason  to  regret  having  done  so.  When  the  lung  is 
injured  the  external  wound  should  not  be  closed.  The  blood  should 
be  allowed  to  escape  externally,  to  prevent  an  accumulation  in  the 
cavity  of  the  chest,  which  would  produce  much  more  serious  conse- 
quences. Should  the  external  wound  be  too  small  for  the  escape  of 
the  blood,  and  if  you  have  ascertained  by  percussion  and  auscultation 
that  it  has  accumulated  in  the  cavity,  either  the  original  wound 
should  be  enlarged,  or  another  made  at  a  more  convenient  place,  to 
allow  it  to  escape.  In  such  cases  the  patient  is  generally  unable  to  lie 
down,  except  on  the  injured  side.  The  function  of  the  lung  on  that 
side  being  destroyed,  it' the  other  should  be  embarrassed  by  position, 
as  much  air  would  not  enter  the  lung  as  the  system  requires.  In 
such  cases  the  respiratory  murmur  is  absent,  and  there  is  a  want  of 
resonance  on  percussion.  There  is  another  symptom  avhich  is  sel- 
dom absent,  and  that  is  retention  of  urine;  when  the  posterior 
portion  of  the  lung  is  wounded,  I  have  almost  always  found  it 
necessary  to  use  the  catheter  for  several  days.  Sometimes  suppura- 
tion results  from  the  presence  of  blood  in  the  chest,  and  then  you 
must  treat  it  as  already  recommended. 

Emphysema  results  from  a  wound  of  a  lung  produced  by  a  frac- 
tured rib,  or  other  causes,  so  as  to  allow  the  air  to  pass  into  the  sub- 
cutaneous cellular  tissue,  by  which  it  sometimes  becomes  greatly 
distended,  and  one-half  of  the  body  very  much  disfigured.  One  of 
the  most  extraordinary  cases  I  have  ever  seen  was  produced  by  an 
operation  which  I  performed  some  years  since  upon  a  young  man 
who  had  a  cavity  in  the  left  lung,  which  discharged  into  the  pleural 
cavity,  and  the  pus  accumulated  so  much  that  when  he  would  shake 
his  body  quickly  one  could  hear  the  fluid  splash  from  side  to  side  like 
water  in  a  half-filled  barrel.  Having  been  very  successful  with  the 
drainage-tube,  I  decided  to  open  the  chest,  draw  off  the  pus,  and 
allow  it  to  escape  gradually,  hoping  that  if  the  case  was  not  cured, 
temporary  relief  might  be  afforded. 

When  the  external  opening  was  made  and  the  contents  discharged, 
the  air  escaped  at  every  inspiration,  there  being  a  connection  between 
the  external  wound  and  the  bronchial  tubes.  I  inserted  a  tube, 
closed  it  with  cork,  dressed  it  as  usual,  and  in  three  hours  I  was 
sent  for  and  found  that  one  side  of  his  body  was  enormously  swollen. 
A  firm  compress*  was  applied,  the  tube  remaved,,  and  the  skin  was- 

23 


354          LECTURES  ON  PRACTICAL  SURGERY. 

pricked  in  different  places,  which  with  friction  was  sufficient  to 
remove  the  difficulty  in  a  very  short  time.  On  passing  the  hand 
over  a  part  similarly  affected,  a  noise  is  heard,  which  results  from 
the  passage  of  the  air  from  cell  to  cell.  Empyema  is  a  collection 
of  fluid  in  the  pleural  cavity,  and  emphysema  and  pneumothorax 
are  produced,  the  latter  by  the  escape  of  air  into  the  cavity  of  the 
pleura,  and  the  former  into  the  subcutaneous  cellular  tissue,  which 
gives  rise  to  the  symptoms  detailed. 

Pneumothorax  may  be  easily  distinguished  by  the  increase  of 
resonance.  It  is  rarely  serious ;  for  when  the  wound  heals  the  air  is 
absorbed,  and  the  difficulty  of  respiration  disappears.  When  accu- 
mulations of  pus  or  serum  take  place  in  the  chest,  and  resist  the 
ordinary  methods  of  treatment,  you  can  calculate  with  confidence 
that  in  eight  cases  out  often  the  treatment  indicated  will  prove  suc- 
cessful. Make  an  opening  above  and  near  the  body  of  the  rib, 
insert  the  tube  described,  empty  the  sac  every  two  or  three  hours; 
the  cavity  in  ordinary  cases  will  gradually  close,  and  the  patient  be 
restored  to  health.  But  in  cases  of  a  strumous  character,  neither 
this  nor  any  other  treatment  can  be  followed  by  a  satisfactory  result. 


LECTURE    XXXIII.  —  WOUNDS    OF    ABDOMEN.  355 


LECTURE    XXXIII. 


GENTLEMEN  :  I  shall  to-day  direct  your  attention  to  wounds  of 
the  abdomen.  When  the  peritoneum  is  not  injured,  these  are  not 
more  dangerous  than  superficial  wounds  of  any  other  portion  of  the 
body,  and  hence  do  not  require  special  treatment.  When,  however, 
that  membrane  is  wounded,  they  are  extremely  dangerous,  more  or 
less  so  according  to  the  extent  and  character  of  the  injury,  or,  in 
other  words,  to  the  importance  of  the  other  organs  implicated.  A 
wound  of  the  abdomen  may  be  either  punctured,  incised,  or  lacerated. 

A  punctured  wound  is  as  serious  as  any  other,  when  the  perito- 
neum arid  other  important  parts  are  involved.  An  incised  wound  is 
generally  more  extensive,  and  when  the  intestines  are  injured  they 
will  require  such  treatment  as  will  hereafter  be  indicated.  Lacerated 
wounds  are  almost  always  produced  by  firearms,  and  of  course  are 
both  lacerated  and  punctured.  They  are  more  dangerous  than  in- 
cised wounds  of  the  same  part,  and  although  not  always  fatal,  as  will 
hereafter  appear,  they  generally  are  followed  by  that  result.  The 
peritoneum  is  a  serous  membrane,  and  therefore  inflames  readily, 
which  explains  the  great  danger  of  all  the  injuries  sustained  by  it, 
however  produced.  There  is  seldom  much  haemorrhage  in  wounds 
of  the  abdomen,  by  reason  of  the  pressure  made  by  the  contraction  of 
the  abdominal  muscles  being  sufficiently  great  to  close  the  wounded 
vessels.  When  it  does  occur  the  blood  generally  escapes  externally. 

When  the  intestines  are  wounded,  the  case  presents  a  serious 
aspect.  Blood  is  mixed  with  the  alvine  discharges,  while  faecal 
matter  and  blood  pass  through  the  wound.  I  treated  a  case  a  few 
years  ago  which  was  one  of  the  most  disgusting  and  discouraging 
that  I  have  ever  met  with.  Two  drunken  Irishmen  were  fighting, 
when  one  stabbed  the  other,  making  with  a  knife  a  wound  four  or 
five  inches  in  length,  through  which  the  wounded  intestines  pro- 
truded. The  man  wore  a  flannel  shirt  and  drawers ;  after  he  had 
received  the  wound  he  went  to  the  privy,  and  was  found  there  with 
a  mass  of  the  intestines  as  large  as  a  fist  protruding,  and  covered 


356          LECTURES  ON  PRACTICAL  SURGERY. 

with  sand  and  wool  from  his  drawers  and  shirt.  It  was  late  at 
night*  and  after  two  or  three  hours  had  been  spent  in  the  removal 
of  the  extraneous  matter  from  the  protruding  parts,  I  closed  the 
wounds,  both  in  the  intestine  and  in  the  abdominal  parietes.  This 
case  terminated  unfavorably,  as  will  almost  every  case  of  this  char- 
acter. The  wound  of  the  abdomen  was  closed  by  the  interrupted 
silver  suture,  after  the  edges  of  the  wound  of  the  colon  (which  was 
the  intestine  injured)  had  been  inverted,  and  the  serous  surfaces 
brought  in  contact  by  the  interrupted  silk  suture;  but  the  patient 
died  of  peritonitis  in  twenty-four  hours  after  the  receipt  of  the  injury. 
In  simple  wounds  of  the  abdominal  parietes,  the  silver  suture  should 
be  used.  Should  the  peritoneum  be  wounded,  and  the  intestines 
uninjured,  the  latter  should  be  returned,  and  the  wound  closed  as 
previously  directed.  In  closing  wounds  of  the  abdomen,  the  needle 
used  should  not  injure  the  peritoneum,  although  it  should  pass  as 
near  the  bottom  of  the  wound  as  possible,  in  order  to  secure  union 
by  the  first  intention,  and  the  ligatures  or  sutures  should  be  allowed 
to  remain  six  or  seven  days.  Should  inflammation  follow  such  an 
injury,  the  case  may  be  absolutely  hopeless  from  the  outset;  but  if 
not,  it  may  be  proper  to  abstract  blood  both  generally  and  locally. 
Calomel  and  opium  should  be  administered  to  relieve  pain  and  pro- 
mote secretions  from  the  important  organs,  as  well  as  to  obtain  the 
specific  effect  of  the  former,  provided  the  consequences  of  the  injury 
are  protracted,  or  in  other  words  become  chronic.  Many  physicians, 
both  in  this  city  and  elsewhere,  are  opposed  to  the  use  of  the  lancet, 
because  they  have  not  sufficient  independence  and  self-confidence  to 
withstand  public  opinion. 

There  are  two  reasons  why  we  do  not  bleed  as  much  as  we  did 
formerly ;  the  first  has  been  mentioned,  and  the  second  is  that  we 
have  depressants,  which  in  six  or  eight  hours  will  reduce  the  pulse 
to  its  natural  standard,  where  it  can  be  kept  by  a  continuation  of 
the  remedies.  Consequently  when  the  symptoms  are  not  very  ur- 
gent, they  can  be  relied  upon ;  but  when  the  inflammation  is  acute, 
depressants  do  not  relieve  the  capillary  vessels  so  effectually  as  vene- 
section. Resort  to  both,  and  apply  the  warm-water  dressings;  pre- 
vent evaporation  by  the  use  of  oiled  silk  and  a  bandage,  which  I 
consider  preferable  to  any  other  application  in  such  cases. 

The  serous  membranes  adhere  readily  if  brought  and  retained  in 
contact,  plastic  lymph  will  be  secreted,  and  the  wound  will  close  in 


LECTURE    XXXIIT.  —  WOUNDS    OF    ABDOMEN.  357 

a  shorter  time  than  is  required  by  any  other  tissue  or  tissues  of  the 
body.  The  edges  of  wounds  of  the  intestine  must  be  inverted  ;  the 
serous  surfaces  are  thus  approximated,  and  may  be  retained  in  con- 
tact by  the  interrupted  silk  suture.  Lymph  will  soon  be  secreted  to 
cover  the  sutures,  which  will  pass  into  the  cavity  of  the  wounded  intes- 
tine, and  in  a  few  days  no  inconvenience  will  be  experienced  from 
the  injury.  Do  not  forget  that  the  edges  of  a  wounded  mucous 
membrane,  when  approximated,  will  not  heal  by  the  first  intention, 
because  the  stitches  will  be  thrown  off  by  ulceration  before  union 
takes  place. 

When  an  intestine  is  wounded,  allow  me  to  repeat,  remove  all 
foreign  bodies  from  the  protruding  part,  invert  the  edges  of  the 
wound,  hold  the  serous  surfaces  of  the  wound  in  contact  by  the  in- 
terrupted silk  suture,  return  the  part  into  the  cavity  of  the  abdomen, 
close  the  external  wound  as  before  directed,  and  then  make  hot  appli- 
cations, and  administer  the  remedies  already  specified.  The  profes- 
sion is  indebted  to  Jobert,  of  the  St.  Louis  Hospital,  for  this  method 
of  treating  injuries  of  this  character.  I  have  made  many  experi- 
ments upon  the  lower  animals,  and  have  treated  wounds  of  the  in- 
testine of  the  human  species  by  pursuing  this  method  with  great 
success.  One  night,  in  this  city,  I  was  called  to  see  a  man  who  had 
received  a  wound  of  the  abdomen.  Fsecal  matter  escaped  from  the 
wound,  but  the  opening  was  not  sufficiently  large  to  allow  the  intes- 
tine to  protrude.  It  was  enlarged,  the  wound  in  the  intestine  was 
exposed  and  closed,  and  the  patient  recovered  without  experiencing 
any  serious  inconvenience  from  the  injury.  I  have  treated  other 
cases  in  my  native  State  with  the  same  result.  The  diet  should  con- 
sist of  chicken-water,  corn-meal  gruel,  or  milk,  if  preferred.  Noth- 
ing should  be  allowed  that  can  distend  the  intestines,  and  the  bowels 
should  be  kept  constipated  for  four  or  five  days,  and  then  opened  by 
an  enema  composed  of  an  infusion  of  Sj  of  senna  to  the  pint  of 
water.  Dr.  William  Bettson,  of  Colusa,  gave  me  the  particulars  of 
a  case  that  occurred  at  the  battle  of  Gettysburg.  A  rifle-ball  passed 
into  the  abdomen  above  Poupart's  ligament,  and  the  next  day  was 
discharged  by  the  rectum,  and  the  man  suffered  no  more  inconve- 
nience than  would  have  resulted  from  a  gunshot  wound  of  the 
abdominal  parietes.  Beaumont,  of  St.  Louis,  treated  a  very  remark- 
able case  of  wound  of  the  stomach,  and  made  many  experiments 
which  were  exceedingly  valuable  to  the  profession. 


358  LECTURES    ON    PRACTICAL    SURGERY. 

The  bladder  is  also  liable  to  be  wounded.  Injuries  of  this  char- 
acter have  always  been  regarded  as  fatal.  That  opinion  I  entertained 
until  about  four  years  ago,  when  one  morning  I  met  the  class  at  the 
County  Hospital,  and  was  told  that  a  man  had  been  admitted  with 
a  wound  of  the  bladder.  The  incision  was  three  inches  long,  in  the 
centre  of  the  abdomen,  and  the  urine  was  flowing  through  a  large 
silver  catheter,  introduced  by  the  nurse  when  he  was  admitted.  I 
had  a  few  days  before  told  the  nurse,  that  if  a  patient  with  a  wound 
of  the  bladder  should  be  admitted  during  my  absence,  he  must  intro- 
duce a  No.  6  or  8  silver  catheter,  secure  it,  and  keep  the  patient 
upon  the  side  until  I  arrived.  The  nurse  had  treated  the  case  as 
I  directed.  The  patient's  position  was  changed  from  side  to  side, 
and  in  less  than  two  weeks  he  had  recovered  sufficiently  to  leave 
the  hospital.  Unfortunately  he  was  murdered  a  few  weeks  later,  at 
Sacramento,  by  one  of  the  fast  men  of  that  city.  Wounds  of  the 
bladder  have  been  regarded  as  incurable,  because  of  the  risk  of 
urinary  infiltration,  which  when  extensive  is  almost  always  fatal. 
This  difficulty  occurs  occasionally  in  California,  by  caves  and  the 
detachment  of  boulders  in  tunnels.  The  consequences  of  such  inju- 
ries will  be  considered  elsewhere. 

In  cases  of  infiltration  of  urine,  no  matter  how  produced,  in  order 
to  save  the  patient,  numerous  punctures  should  be  made  with  a  lan- 
cet, and  the  urine  forced  out  through  the  openings.  Use  cloths,  wet 
with  warm  water,  and  sufficient  pressure  to  force  the  urine  out,  for 
if  it  remains,  mortification  and  death  must  follow.  When  affections 
of  the  abdominal  cavity  were  under  consideration,  I  mentioned  the 
operation  of  paracentesis  abdominis,  but  did  not  describe  how  it 
should  be  performed.  It  sometimes  becomes  necessary  to  remove 
serum  from  the  peritoneal  cavity,  produced  either  by  inflammation 
of  that  membrane  or  by  induration  of  the  liver  or  spleen,  or  both, 
by  which  the  circulation  in  the  capillaries  is  disturbed.  They  be- 
come congested,  an  increased  secretion  takes  place,  more  than  is  nec- 
essary to  supply  the  parts,  it  accumulates,  and  is  then  called  dropsy. 
When  the  accumulation  becomes  so  great  as  to  cause  distension  and 
inconvenience  in  breathing,  if  it  cannot  be  removed  by  diuretics, 
you  should  perform  the  operation  of  paracentesis  abdominis,  which 
consists  in  passing  a  trocar  and  canula  through  the  abdominal  walls. 
The  serum  will  flow  through  the  canula  until  the  fluid  has  all  es- 
caped, when  the  wound  should  be  closed  by  a  strip  of  adhesive  plaster 


LECTURE    XXXIII.  —  TAPPING.  359 

and  a  bandage.  The  trocar  should  be  inserted  either  at  the  centre, 
between  the  umbilicus  and  pubis,  in  the  linea  alba,  or  at  the  mid- 
point of  a  line  drawn  from  the  anterior  superior  spinous  process  of 
the  ilium  to  the  umbilicus.  Both  are  equally  safe.  The  execution 
is  simple,  but  always  be  sure  that  you  are  right,  because  you  might 
perform  the  operation  of  dry  tapping,  and  that  would  be  exceedingly 
unpleasant.  When  I  was  a  medical  student  this  was  considered  a 
great  operation.  I  rode  fifteen  miles  to  see  it  performed,  and  when 
we  reached  the  place  the  patient  was  sitting  in  a  large  armed  chair, 
in  the  shade  of  a  large  oak  tree  near  the  house,  for  the  accommoda- 
tion of  the  five  or  six  hundred  people  who  had  assembled  to  witness 
this  surgical  achievement.  How  things  have  changed  ! 

Before  performing  this  operation,  be  sure  that  you  have  a  case  of 
abdominal  dropsy.  Sir  Astley  Cooper  gives  a  case  that  occurred  in 
London.  The  physician  of  the  patient  thought  he  had  a  case  of 
ascites,  passed  a  trocar  through  the  abdominal  parietes,  and  as  no 
fluid  followed  the  withdrawal  of  the  trocar,  he  said,  "Gentlemen,  you 
have  witnessed  the  operation  of  dry  tapping,  which  you  may  never 
see  again."  The  students  of  the  Toland  College  once  enjoyed  that 
privilege  in  a  medical  ward  in  the  County  Hospital.  When  fluctua- 
tion is  not  distinct,  in  other  words,  if,  the  left  hand  being  placed  upon 
one  side  of  the  abdomen,  and  the  other  side  gently  percussed  with 
the  right,  a  wave  of  fluid  is  not  felt  to  strike  against  the  place  covered 
by  the  left  hand,  you  should  use  the  exploring  needle,  by  which  is 
meant  either  a  simple  grooved  needle  or  the  small  trocar  and  canula, 
which  I  have  used  in  diagnosing  abscesses  of  the  liver  and  deep- 
seated  abscesses  in  other  portions  of  the  body,  as  well  as  ascites.  I 
can  say  to  the  strangers  in  this  class,  that  I  have  never  made  a  mis- 
take in  my  life  in  the  diagnosis  of  either  serous  or  purulent  secre- 
tions. Should  the  tumor  be  of  a  different  character,  the  use  of  the 
exploring  needle  will  not  be  followed  by  any  serious  inconvenience. 
Sometimes  an  effusion  of  serum  takes  place  between  the  skin  and  the 
abdominal  parietes,  or  a  superabundance  of  fat  might  be  mistaken 
for  dropsy.  But,  gentlemen,  I  now  caution  you  to  always  be  careful 
not  to  mistake  a  case  of  ascites  for  ovarian  dropsy  or  tumor. 

After  the  operation  of  paracentesis  abdominis,  a  tight  bandage 
should  be  applied,  and  stimulants  administered  until  the  patient 
becomes  accustomed  to  the  absence  of  the  distension. 

Children  frequently  put  foreign  bodies  into  the  nose,  and  some- 


360  LECTURES    ON    PRACTICAL    SURGERY. 

times  the  efforts  made  by  the  friends  render  their  removal  very 
difficult.  To  remove  such  obstructions  there  is  nothing  better  than 
a  pair  of  small  curved  forceps,  and  when  the  substance  cannot  be 
grasped  or  removed  by  means  of  a  director  or  hair-pin,  I  always 
take  a  director,  pass  it  above  the  foreign  substance,  and  press  it  down 
into  the  inferior  strait,  from  which  it  passes  into  the  throat,  and  is 
thrown  out  or  swallowed,  when  the  nose  is  relieved.  An  anaesthetic 
will  greatly  facilitate  such  operations,  and  as  in  such  cases  the  patient 
is  very  apt  to  make  all  the  resistance  possible,  he  must  be  entirely 
under  the  influence  of  chloroform.  When  the  forceps  are  introduced, 
and  you  are  ready  to  take  hold  of  the  bean,  bud,  watermelon-seed, 
or  grain  of  corn,  the  slightest  motion  of  the  head  will  defeat  or  pre- 
vent the  success  of  the  effort.  I  generally  give  the  chloroform  my- 
self. The  arms  are  tied  to  the  arms  of  a  strong  barber's  chair, 
which  I  have  always  kept  in  my  office.  The  body  is  made  fast  to 
the  back  of  the  chair  by  a  strong  bandage,  then  I  hold  the  head 
firmly,  so  that  my  assistant  can  take  hold  of  the  body  and  remove  it, 
if  removal  is  possible,  and  if  not,  I  pursue  the  course  of  treatment 
already  indicated.  I  would  rather  perform  any  capital  operation, 
particularly  at  night,  than  remove  a  glass  button  or  any  other 
smooth,  hard,  oval,  or  round  substance  from  the  nose.  The  friends 
are  not  satisfied  to  have  it  pushed  back  into  the  throat,  and  hence 
you  should  always  endeavor  to  present  it  to  them. 

There  is  another  difficulty  of  the  nose  which  is  sometimes  annoy- 
ing, and  occasionally  dangerous,  I  mean  epistaxis  or  haemorrhage. 
The  instrument  exhibited  is  called  Bellocq's  sound,  which  is  intended 
to  enable  you  to  plug  up  the  posterior  nares  in  obstinate  cases  of 
hemorrhage.  A  ligature  is  attached  to  a  piece  of  sponge  large 
enough  to  fill,  when  wet,  the  posterior  nares.  The  sound  is  passed 
through  the  nose,  behind  the  soft  palate,  and  into  the  mouth.  The 
sponge  is  attached  to  the  extremity  of  the  sound,  and  drawn  into  the 
posterior  nares,  and  retained  there  until  the  danger  of  a  recurrence 
has  subsided.  After  this  has  been  secured  the  external  nares  should 
be  plugged  either  with  lint  or  cotton,  and  then  it  is  impossible  for 
the  haemorrhage  to  continue.  I  have  practiced  a  long  time,  and  have 
had  this  instrument  about  thirty-five  years,  but  I  have  never  found  it 
necessary  to  use  it.  I  have  loaned  it  frequently,  but  never  found  it 
necessary  in  any  case  I  have  treated.  In  order  to  demonstrate  what 
I  mean,  some  years  ago,  about  five  o'clock  in  the  afternoon,  I  was 


LECTURE    XXXIII, — FOREIGN    BODIES    IN    EAR.  361 

called  to  see  a  patient  at  the  Lee  House,  who,  they  said,  was  bleeding 
to  death  from  the  nose.  I  found  three  or  four  physicians  present, 
and  they  could  not  arrest  the  haemorrhage.  I  took  with  me  some 
powdered  alum  and  a  roll  of  lint.  So  soon  as  I  arrived,  the  lint, 
after  being  wet,  was  covered  with  the  powdered  alum,  and  inserted 
into  the  superior  strait  of  the  nares,  and  packed  firmly.  The  haem- 
orrhage ceased  instantly,  and  the  man  they  thought  would  be  sent 
home  a  corpse,  is  now  living,  and  survived  his  expected  funeral  at 
least  fifteen  years.  Pulverized  bluestone  or  sulphate  of  copper  an- 
swers the  same  purpose.  It  is  more  painful  than  alum,  and  is  not 
so  effectual  as  the  persulphate  of  iron,  or  Monsel's  salt,  which  I 
introduced  many  years  ago  as  a  powerful  haemostatic.  I  claim  the 
credit  of  being  the  first  in  America  who  introduced  the  remedy,  and 
who  published  an  article  in  a  medical  journal  describing  its  proper- 
ties. When  you  have  a  case  of  haemorrhage  from  the  nose,  which 
has  resisted  the  ordinary  remedies,  take  strips  of  lint  half  an  inch 
wide,  and  wet,  cover  them  with  Monsel's  salt,  and  pass  them  into  the 
superior  strait,  plugging  up  the  external  nares,  at  least  the  side  from 
which  the  blood  escapes,  and  the  haemorrhage  will  not  return.  The 
haemorrhage  almost  if  not  always  comes  from  the  superior  strait. 
I  apply  my  local  remedy  there,  and  I  have  never  been  disap- 
pointed. Should  blood  flow  from  the  other  nostril,  this  should  also 
be  plugged  with  lint  covered  with  Monsel's  salt,  and  the  haem- 
orrhage can  always  be  controlled  without  the  use  of  Bellocq's  sound. 
You  should  not  rely  upon  stopping  the  nostrils  externally,  for  the 
blood  will  pass  into  the  throat.  Pressure  must  be  made  upon  the 
bleeding  vessel,  and  I  repeat  that  it  is  usually  found  in  the  upper 
part  of  the  nose,  and  from  my  experience  I  might  say  that  it  always 
is  when  the  haemorrhage  does  not  result  from  an  injury. 

Foreign  bodies,  such  as  glass  buttons,  beads,  beans,  or  grains  of 
corn,  or  anything  that  is  small  enough,  may  be  found  in  the  ear, 
and  occasionally  great  difficulty  will  be  experienced  in  their  re- 
moval. Some  years  ago,  a  boy,  four  or  five  years  of  age,  put  a 
glass  button,  thick  in  the  centre,  thin  at  the  edges,  and  perfectly 
smooth,  in  one  of  his  ears.  It  could  be  easily  seen  and  felt,  but  in 
consequence  of  some  peculiarity  it  was  impossible  to  render  him 
sufficiently  insensible  to  touch  his  ear  without  his  knowledge. 
Finding  that  the  ordinary  forceps  slipped,  I  had  the  blades  of  the 
most  approved  apparatus  covered  with  chamois  leather,  and  still  it 


362          LECTURES  ON  PRACTICAL  SURGERY. 

could  not  be  removed.  It  was  finally  removed  by  placing  the  pa- 
tient on  that  side  and  throwing  a  stream  of  tepid  water  into  the  ear 
until  it  was  washed  out.  The  chloroform  given  came  very  near 
proving  fatal ;  the  boy  appeared  to  be  in  a  stupor  for  several  days, 
and  was  kept  alive  by  stimulants,  administered  every  two  or  three 
hours  until  the  stupor  disappeared  and  the  vomiting  ceased.  The 
pulse  for  two  days  was  40,  and  he  exhibited  all  the  symptoms  of 
protracted  anaesthesia,  which  convinced  me  that  the  use  of  chloro- 
form becomes  dangerous  in  proportion  to  the  length  of  time  it  is 
administered. 


LECTURE    XXXIV. —  POLYPUS    OF    THE    NOSE.  363 


LECTURE    XXXIV. 

GENTLEMEN  :  This  lecture  will  be  upon  the  nose  and  ears,  and 
I  will  direct  your  attention  to  polypus,  which  is  a  growth  that  forms 
in  the  nose,  and  of  course,  when  it  becomes  large,  obstructs  the  pas- 
sage and  renders  respiration  difficult.  There  are  three  varieties: 
1st.  The  mucous;  2d.  The  fibrous;  3d.  The  medullary.  The  mucous 
polypus  is  soft,  sometimes  transparent,  and  occasionally  presents  a 
slightly  reddish  appearance.  It  is  soft  and  yields  to  very  slight 
pressure,  but  sometimes  it  can  be  removed  entire.  It  appears  to  be  a 
hypertrophy  of  the  mucous  membrane,  and  the  attachment  or  pedicle 
is  usually  small. 

The  fibrous  polypus  is  entirely  different;  it  is  as  solid  as  an  ordi- 
nary fibrous  tumor,  and  when  it  acquires  considerable  magnitude 
it  passes  into  the  throat,  behind  the  soft  palate.  The  medullary 
polypus  grows  rapidly,  bleeds  readily,  and  is  almost  always  painful, 
and  is  generally  accompanied  by  the  symptoms  that  usually  attend 
malignant  diseases. 

Mucous  polypi  are  easily  removed,  but  are  very  liable  to  return. 
I  have  found  since  Monsel's  salt  was  discovered,  and  for  the  first 
time  used  in  this  State,  that  the  best  method  of  treating  mucous 
polypus  of  the  nose  is  to  pass  a  director  covered  with  wet  lint,  satu- 
rated with  MonsePs  salt,  into  the  diseased  nostril ;  by  the  passage 
of  the  lint  the  polypus  is  broken  down,  and  by  repeating  it  a  few 
times  the  difficulty  disappears.  The  treatment  with  lint  and  Mon- 
sel's salt  has  superseded  the  use  of  the  polypus  forceps,  which  I 
never  employ  except  in  cases  of  mucous  polypus  of  the  uterus,  which 
are  easily  removed  and  their  return  prevented  by  the  use  of  Monsel's 
salt. 

I  have  treated  but  one  case  of  fibrous  polypus  of  the  nose.  In 
that  case  the  tumor  commenced  in  the  nose,  and  as  it  enlarged  it 
passed  backward  behind  the  soft  palate,  and  extended  about  an  inch 
below  the  uvula.  Deglutition  was  extremely  difficult,  and  it  be- 


364  LECTURES    ON    PRACTICAL    SURGERY. 

came  necessary,  to  prevent  death  from  inanition,  to  perform  an 
operation  by  which  the  tumor  could  be  removed,  but  which  my 
partner,  Dr.  Thomas  Wells,  contended  would  prove  fatal  by 
hemorrhage.  He  thought  the  haemorrhage  could  not  be  arrested  by 
any  means  within  the  control  of  the  profession.  I  had  a  pair  of 
strong  forceps  made,  with  teeth,  and  curved  so  as  to  pass  up  behind 
the  soft  palate,  which  was  thrown  forward  by  the  pressure  made  by 
the  tumor.  They  were  strong  enough  not  to  yield  if  my  entire 
strength  was  applied.  The  forceps  was  passed  up  behind  the  soft 
palate,  and  the  tumor  was  grasped  as  near  the  base  as  possible. 
Before  removing  the  tumor,  after  the  application  of  the  forceps,  I 
had  a  wash-basin  filled  with  a  saturated  solution  of  the  sulphate  of 
copper,  in  which  was  a  quantity  of  lint.  When  the  tumor  was 
removed  the  haemorrhage  was  frightful,  until  it  was  arrested  by 
plugging  up  the  posterior  nares  with  lint,  saturated  with  the  solution 
of  the  sulphate  of  copper.  The  soft  palate  had  been  displaced  so 
much  that  I  could  pass  my  finger  behind  it  and  fill  the  cavity  so 
effectually  that  haemorrhage  could  not  under  any  circumstances  con- 
tinue. 

Malignant  polypus  is  a  very  different  disease;  when  removed 
with  the  polypus  forceps  it  generally  bleeds  freely,  and  is  very  liable 
to  return.  Some  years  since  I  treated  a  case  from  Calaveras  County. 
I  removed  the  tumor  three  or  four  times,  but  the  patient  only  expe- 
rienced temporary  relief.  I  then  proposed  to  make  an  external 
incision  for  the  purpose  of  removing  the  bones  that  were  implicated, 
but  having  friends  at  the  East,  he  concluded  to  visit  them  and  then 
enter  a  public  hospital,  and  submit  to  the  treatment  recommended. 

There  is  another  difficulty  of  the  nose  which  occurs  occasionally,  and 
is  frequently  very  obstinate,  which  is  ulceration  of  the  septum.  This 
is  a  disease  of  a  strumous  character,  and  commences  in  the  mucous 
membrane,  and  when  that  is  destroyed  by  ulceration,  the  cartilage  is 
absorbed  and  communication  is  established  between  the  nasal  cavi- 
ties. Deformity  of  the  nose  seldom  occurs,  and  I  think  the  disease 
can  be  generally  arrested  before  the  destruction  becomes  extensive. 
I  have  succeeded  in  arresting  this  difficulty  by  the  use  of'  both  the 
iodide  of  potassium  and  iodide  of  iron,  in  the  shape  of  Blancard's 
pills.  As  a  local  remedy  I  prefer  the  chlorate  of  potassium  ;  a 
saturated  solution  should  be  applied  two  or  three  times  a  day  with  a 
camePs-hair  pencil.  With  the  iodide  of  potassium  I  sometimes 


LECTURE    XXXIV. — DISEASES    OF    THE    NOSE,  365 

combine  the  fluid  extract  of  stillingia,  which  during  the  war  I  was 
compelled  to  abandon  in  consequence  of  the  price,  as  it  is  indigenous 
to  the  South.  Another  and  perhaps  the  most  formidable  disease  of 
this  organ  is  lupus,  formerly  called  noli  me  tangere,  which  means 
don't  touch  me,  because,  if  you  do  you  cannot  increase  your  reputa- 
tion by  effecting  a  cure*  The  disease  originates  in  the  sebaceous 
follicles  of  the  face,  and  it  often  extends  until  the  nose  as  well  as 
other  portions  of  the  face  are  destroyed r  and  is  the  cause  frequently 
of  ectropion  when  the  ulcers  heal.  Females  are  more  liable  to  it  than 
males.  The  skin  becomes  inflamed  and  at  length  ulcerates,  and  the 
ulcer  has  a  tendency  to  enlarge  constantly  and  sometimes  rapidly, 
and  often  before  the  disease  can  be  arrested  permanent  deformity 
may  result.  The  best  internal  remedy  is  Fowler's  sol.  of  arsenic  with 
senna.  1^.  Fowler's  sol.,  5iv ;  fluid  ext.  senna,  §iij  ;  syr.  simplicis 
or  zingiberis,  Siiss.  Misce.  Sig.  Give  one  teaspoonful  three  times- a 
day,  in  water,  after  meals.  Fowler's  solution  should  be  applied  to 
the  edge  of  the  ulcer  two  or  three  times  a  week  until  its  progress  is 
arrested.  Some  authors  recommend  four  grains  of  arsenic  to  a  quart 
of  water  to  be  applied  morning  and  evening.  I  have  used  nitric 
acid  with  a  decidedly  good  effect.  Take  a  redwood  stick  about  the 
size  of  an  ordinary  lead-pencil,  dip  the  end  into  nitric  acid,  and  touch 
the  ulcer  four  or  five  times  at  intervals  of  three  days;  allow  it  to 
remain  two  or  three  minutes,  and  then  wash  it  off  with  cold  water. 
This  treatment,  when  applied  to  any  painful  or  irritable  ulcer,  relieves 
the  pain  more  speedily  and  effectually  than  any  other.  The  ulcer 
should  ordinarily  be  dressed  with  simple  cerate. 

There  is  another  difficulty  of  the  nose  which  is  occasionally  met 
with,  and  that  is  hypertrophy ;  it  is  generally  called  a  whisky  nose, 
yet  it  sometimes  occurs  in  persons  who  never  have  indulged  in  the 
use  of  any  alcoholic  stimulants,  of  which  beer  is  the  most  injurious. 
The  nose  enlarges  until  it  acquires  three  times  its  natural  magnitude. 
This  enlargement  is  due  simply  to  an  increased  development  of  the 
cellular  tissue.  This  disease  may  be  hereditary.  One  of  the  judges 
of  the  Supreme  Court  of  this  State  has  transmitted  it  to  about  two- 
thirds  of  his  children.  This  is  a  subject  to  which  I  refer  very  un- 
willingly, but  it  is  of  so  much  importance  that  I  cannot  pass  it  over 
with  only  stating  the  facts.  A  hint  to  the  wise  is  sufficient. 

If  my  nose  presented  that  appearance  I  would  have  it  diminished 
in  size,  and  no  serious  consequence  could  result  from  the  operation. 


366          LECTURES  ON  PRACTICAL  SURGERY. 

The  skin  of  the  nose  should  be  divided  in  the  centre,  and  the  excess 
of  subcutaneous  cellular  tissue  should  be  removed,  so  as  to  reduce 
the  organ  to  its  natural  size.  The  patient  would  not  be  much  dis- 
figured, and  very  little  risk  would  be  incurred  by  such  an  operation. 
Children  often  suffer  from  tympanitis;  in  such  cases,  if  they  be 
neglected,  the  tympanum  may  ulcerate,  and  the  hearing  be  per- 
manently impaired.  I  now  wish  to  impress  upon  every  student  in 
this  college  the  necessity  of  applying  leeches  when  otitis  exists.  The 
number  should  depend  upon  the  violence  of  the  pain  and  the  age 
and  constitution  of  the  patient.  After  the  abstraction  of  blood,  a 
blister,  or  rather  Birt's  blistering  fluid,  should  be  applied  behind  the 
ear  or  ears,  and  when  the  true  skin  is  denuded,  from  a  fourth  of  a 
grain  to  a  grain  of  morphia,  according  to  the  age  of  the  patient, 
should  be  applied  to  the  raw  surface  morning  and  evening  until  the 
pain  subsides ;  should  it  be  violent,  apply  paper  wet  with  strong  am- 
monia; apply  it  to  the  temple,  place  a  four-bit  piece  over  it,  press 
firmly  upon  it  for  about  five  minutes,  and  then  the  cuticle  can  be 
removed  and  the  morphia  applied,  which  may  be  repeated  three  or 
four  times  a  day.  In  tympanitis  the  hearing  when  neglected  should 
not  be  entirely  lost.  In  such  cases  an  examination  may  be  made 
either  with  the  auriscope  or  by  sunlight,  which  is  much  more  satis- 
factory. In  cases  which  have  been  neglected,  and  in  which  ulcera- 
tion  has  already  occurred,  all  that  can  be  done  is  to  control  the 
inflammation  by  leeches,  blisters,  and  the  use,  if  a  discharge  exists, 
of  sulph.  aluminse,  gr.  xij ;  vin.  opii,  5ij  ;  aquae  destil.,  Sij.  Misce. 
Sig.  Put  ten  or  fifteen  drops  in  the  ear  morning  and  evening,  or 
three  times  a  day,  as  may  be  indicated.  Should  the  tympanum  even 
be  perforated,  if  the  bones  of  the  internal  fcar  be  healthy,  and  re- 
tain their  natural  positions,  the  hearing  may  be  injured,  but  not 
necessarily  destroyed,  and  will  remain  sufficiently  perfect  for  ordi- 
nary purposes.  When,  however,  the  Eustachian  tube  is  either 
obstructed  or  closed  by  disease  of  the  mucous  membrane,  then  a 
stricture  may  exist.  After  the  acute  inflammation  subsides,  metallic 
bougies  should  be  employed  to  remove  the  stricture.  After  inflam- 
mation of  the  ear  has  continued  for  some  months,  occasionally 
mucous  polypi  are  produced,  which  are  very  liable  to  return  after 
they  have  been  removed.  Remove  them  with  the  forceps,  and  apply 
a  small  piece  of  lint  wet  with  ether  the  saturated  solution  of  MonsePs 
salt,  or  the  salt  itself,  to  the  diseased  surface.  Some  prefer  the  nitrate 


LECTURE    XXXIV.  —  DISEASES    OF    THE    NOSE.  367 

of  silver,  which  I  have  found  frequently  effectual  in  preventing  a 
recurrence  of  the  difficulty.  The  gums,  particularly  of  the  inferior 
maxillary  bone,  are  liable  to  tumors  or  excrescences,  which  are  firm, 
whitish,  and  irregular,  and  if  allowed  to  remain,  finally  become  can- 
cerous. Since  I  have  lived  in  this  city  I  have  treated  four  cases. 
The  tumor,  including  the  gum,  should  be  removed  with  a  gouge, 
and  the  actual  cautery  applied.  The  periosteum  is  the  seat  of  the 
difficulty.  When  that  is  destroyed,  and  the  bone  exfoliates,  the 
disease  will  seldom  return.  I  operated  upon  a  case  of  this  character, 
which  involved  the  alveolar  process  of  the  lower  front  teeth,  and 
they  were  loose.  I  removed  the  diseased  substance  entirely  with 
bone-forceps,  including  both  the  soft  parts  and  bone,  with  the  alveo- 
lar processes.  The  recovery  of  the  patient  was  entirely  satisfactory. 
He  subsequently  obtained  a  set  of  false  front  teeth,  and  was  not 
disfigured. 

Besides  the  diseases  mentioned,  the  maxillary  bones  give  rise  to 
three  varieties  of  tumors :  the  medullary,  cystic,  and  fibro-cartilag- 
inous.  The  first  is  cancerous,  and  unless  you  remove  the  entire 
disease  the  difficulty  will  return ;  often,  too  often  I  am  sorry  to  say, 
it  will  do  so  in  spite  of  your  utmost  care.  Cystic  tumors  always 
form  in  the  interior  of  the  bone.  When  they  appear  in  the  inferior 
maxillary  it  generally  enlarges,  and  the  pressure  causes  an  absorption 
of  the  surrounding  bony  tissue,  which  ultimately  becomes  very  thin, 
so  thin,  indeed,  that  it  can  be  cut  with  a  scalpel.  When  cystic  tu- 
mors form  in  the  antrum  highmorianum,  and  have  enlarged  until 
the  surrounding  bony  tissue  has  been  absorbed,  an  incision  should 
be  made  upon  the  inside  of  the  mouth,  through  the  shell  of  the  bone 
that  remains,  and  the  tumor  removed  with  the  forefinger  of  the  hand 
that  is  most  convenient.  In  1846,  in  Columbia,  South  Carolina,  I 
removed  a  tumor  of  this  character  from  the  antrum,  on  the  left 
side,  by  making  an  incision  the  entire  length  of  the  enlargement, 
and  picking  out  the  tumor  with  the  forefinger  of  the  left  hand.  The 
patient  recovered  rapidly,  and  the  disease  had  not  returned  four 
years  after,  when  I  left  the  State.  In  California,  three  more  cases 
were  operated  upon  in  this  manner,  with  a  similar  result.  By  pur- 
suing this  course  you  avoid  making  a  cicatrix  on  the  face,  which 
would  disfigure  the  patient. 

When  the  tumor  is  of  a  fibro-cartilaginous  character,  you  will  be 
obliged  to  make  an  external  incision,  in  order  to  expose  and  remove 


368  LECTURES    ON    PRACTICAL    SURGERY. 

it.  I  have  never  removed  a  tumor  of  this  character  which  returned. 
But  when  they  are  of  a  medullary  character,  they  almost  always 
return.  Still  you  cannot,  during  the  early  stages  of  the  disease, 
avoid  such  an  operation,  though  you  may  feel  satisfied  that  it  will  be 
unavailing.  The  disease  may  not  return  for  a  long  timey  and  if  it 
should,  it  may  attack  an  internal  organ,  and  when  it  proves  fatal 
the  surgeon  will  not  be  accused  of  homicide,  nor  will  the  patient  be 
subjected  to  the  inconvenience  that  necessarily  results  from  a  can- 
cerous ulcer. 

In  1835,  I  removed  half  of  the  inferior  maxillary  bone  for  a  fibro- 
cartilaginous  tumor,  in  Columbia,.  South  Carolina.  The  boy  was 
twelve  years  old.  I  performed  the  operation  by  the  request  of  Dr. 
Davis,  of  Columbia,  the  most  prominent  physician  of  that  town. 
The  entire  jaw  from  the  articulation  to  the  chin  was  removed,  a 
strong  ligature  being  passed  through  the  tongue,  lest  retraction  of  that 
organ  should  occur,,  which  it  was  supposed  would  prove  fatal.  When 
I  left  the  State  the  patient  enjoyed  good  health,  and  experienced  but 
little  inconvenience,  except  from-  the  want  of  teeth  ;  he  was  very 
slightly  deformed.  I  have  performed  many  operations  of  a  similar 
character,  one  of  which,  for  the  removal  of  the  entire  inferior  max- 
illary bone,  will  be  given  when  the  diseases  of  the  bones  are  under 
consideration. 

Ulceration  of  the  mucous  membrane  of  the  mouth  may  result 
either  from  syphilis  or  from  gastric  derangement.  The  former  will  be 
considered  when  that  class  of  diseases  is  presented.  The  ulcers  may 
appear  upon  the  tongue,  the  mucous  membrane  of  the  mouth  or  the 
throat.  Any  preparation  of  mercury  will  produce  ulceration  of  the 
mouth,  but  the  ulcers  present  a  blackish  appearance,  and  those  re- 
sulting from  gastric  disturbance  are  generally  yellowish.  They  are 
equally  painful,,  b lit  require  very  different  treatment.  In  mercurial 
ulceration  of  the  tongue,  give  iodide  of  potassium  internally,  and 
gargle  with  a  saturated  solution  of  chlorate  of  potash  three  times  a 
day.  I  consider  the  chlorate  of  potash  the  best  antiseptic  we  can 
employ.  A  few  years  ago  I  relied  upon  permanganate  of  potash. 
I  have  since  tried  carbolic  acid,  chloride  of  lime,  and  indeed  every 
new  remedy  that  has  been  presented,,and  I  think  that  the  intelligent 
members  of  the  class  at  the  County  Hospital  are  all  convinced,  from 
the  results  in  my  wards,  that  the  chlorate  of  potash,  is  more  effectual 
than  any  other  preparation*. 


LECTURE    XXXIV.  —  AFFECTIONS    OF    THE    MOUTH.         369 

Sometimes  the  tongue  is  hypertrophied,  and  the  only  possible 
method  of  treatment  is  to  remove  a  sufficient  quantity  of  the  organ 
to  reduce  it  to  its  natural  dimensions.  Dr.  Wells,  my  former 
partner,  in  Columbia,  South  Carolina,  removed  a  hypertrophied 
tongue  by  the  application  of  a  double  ligature,  which  was  passed 
through  the  centre,  tied  firmly,  and  the  portion  anterior  to  the  lig- 
ature was  removed.  The  result  was  satisfactory.  Should  you  meet 
with  such  a  case,  pass  a  four-strand  ligature  through  the  tongue  on 
each  side,  and  give  the  control  of  the  ligatures  to  reliable  parties. 
Take  out  a  Y-shaped  piece  of  the  tongue,  large  enough  to  reduce  the 
organ  to  its  natural  size,  tie  the  arteries,  which  can  be  done  without 
the  slightest  difficulty ;  the  edges  of  the  wound  should  be  approx- 
imated, and  retained  in  contact  by  the  interrupted  silk  suture;  the 
silver  suture  would  prove  a  source  of  great  annoyance. 

The  fraenum  sometimes  extends  to  the  extremity  of  the  tongue,  in 
children,  and  they  are  said  to  be  tongue-tied.  This  is  a  matter  that 
has  annoyed  me  greatly;  every  idiotic  child  over  ten  years  old,  that 
does  not  talk  well,  is  considered  tongue-tied.  I  generally,  in  such 
cases,  divide  the  fra3num  as  far  from  the  tongue  as  possible,  and  say 
to  the  friends  that  every  child  that  can  hear  will  ultimately  talk ; 
this  will  protect  you  from  being  subsequently  annoyed.  It  is  one  of 
the  simplest  operations  in  surgery,  provided  you  cut  as  far  from  the 
tongue  as  possible,  so  as  to  prevent  the  risk  of  haemorrhage. 

The  tonsils  are  liable  to  inflammation,  ulceration,  and  chronic 
enlargement.  Inflammation  of  the  tonsils  is  called  cynanche  ton- 
sillaris.  The  glands  sometimes  become  so  enlarged  that  suffocation 
is  threatened,  and  then  an  incision  should  be  made  upon  both  tonsils; 
since,  by  relieving  the  distension  of  the  inflamed  vessels,  suffocation 
can  almost  always  be  prevented,  and  if  not,  the  pus,  so  soon  as 
formed,  escapes  through  the  incisions.  By  pursuing  this  course  you 
can  anticipate  and  prevent  suppuration.  I  generally  prescribe  a 
gargle,  composed  of  alumin.  sulph.,  5iv;  pulv.  bol.  Armen.,  gr.  x. 
M.  Put  into  a  quart  of  water,  and  gargle  four  or  five  times  a  day. 

When  the  difficulty  is  not  controlled  by  the  treatment  recom- 
mended, an  incision  should  be  made  upon  each  side  of  the  uvula 
above  the  tonsil,  and  where  the  fulness  or  swelling  is  most  prominent. 
This  incision  should  be  made  with  a  tenotomy  knife,  or  a  small 
bistoury,  or  a  lancet  secured  to  a  pencil  or  a  redwood  or  pine  stick, 
sufficiently  strong  to  sustain  the  pressure  or  force  necessary  to  make 

24 


370  LECTURES    ON    PRACTICAL    SURGERY. 

the  incisions.  When  the  tonsils  are  enlarged  and  ulcerated,  you 
should  ascertain  the  constitutional  peculiarities  of  the  patient,  and  if 
delicate,  give  tonics,  quinine  with  the  fluid  ext.  of  senna,  mix  vomica, 
or  iodide  of  iron,  and  apply  nitrate  of  silver  to  the  ulcers  three 
times  a  week.  You  should  also  order  a  nutritious  diet. 

When  permanent  enlargement  of  the  tonsils  exists,  if  the  child  is 
young,  occasionally  the  swelling  will  disappear  by  the  application  of 
a  saturated  solution  of  alum,  applied  with  a  camePs-hair  pencil, 
morning  and  evening.  A  chamois  leather  jacket  should  be  worn 
over  the  flannel  constantly,  and  a  silk  handkerchief  should  be  tied 
around  the  neck,  and  removed  in  the  morning,  and  such  internal 
treatment  should  also  be  recommended  as  the  symptoms  indicate. 
When  this  treatment  fails,  the  tonsils  should  be  cut  off.  In  cases 
of  threatened  suffocation,  I  have  operated  as  early  as  one  year,  but 
although  the  operation  was  successful,  I  prefer,  when  possible,  to  wait 
until  the  child  is  three  or  four  years  old,  and  then  if  the  tonsils  are 
very  large,  only  one  should  be  removed,  which  will  afford  temporary 
relief;  then  at  a  future  and  suitable  time  the  other  should  be  ex- 
cised. The  tonsillotome  is  the  instrument  usually  employed  for 
this  purpose.  The  patient  is  placed  in  an  arm-chair,  and  secured 
either  by  straps  or  assistants.  The  tongue  should  be  held  down 
with  a  spatula.  The  instrument  should  be  placed  over  the  tumor, 
the  points  passed  through,  and  the  tumor  removed  by  the  circular 
blade  concealed  in  the  ring.  I  have  only  used  this  instrument  a 
few  times,  and  finding  that  a  great  deal  of  force  was  required  to  re- 
move an  indurated  tonsil,  I  substituted  the  common  dressing  for- 
ceps and  a  probe-pointed  bistoury,  with  a  cutting  edge  about  an 
inch  and  a  half  in  length,  and  with  that  simple  apparatus  I  can 
operate  in  a  shorter  time,  more  safely  and  more  successfully,  than 
even  an  expert  can  with  the  tonsillotome.  Should  the  patient  bleed 
much  soon  after  the  operation,  cold  water  has  always  in  my  practice 
arrested  the  haemorrhage.  In  two  cases  the  haemorrhage  returned 
the  second  night.  The  first  was  a  little  girl  twelve  years  old  ;  she 
was  relieved  by  the  application  of  lint,  wet  with  the  tinct.  mur. 
ferri,  to  the  bleeding  surface,  which  was  held  in  contact  with  the 
wound  about  five  minutes,  when  the  bleeding  ceased,  and  did  not 
return.  In  the  other  case  the  MonsePs  salt  was  used,  and  the  lint 
was  held  in  contact  with  the  bleeding  surface  about  five  minutes ;  this 
arrested  the  flow,  and  the  gentleman,  who  was  then  the  public  ad- 


LECTURE    XXXIV.  —  THE    TEETH.  371 

ministrator  of  this  city,  recovered  rapidly.  The  teeth,  although  ex- 
ceedingly useful  and  valuable,  are  sometimes  very  troublesome,  and 
it  is  very  important  for  young  people  to  know  how  to  preserve  them. 
The  child  generally  begins  to  cut  its  first  teeth  at  the  age  of  seven 
months,  and  when  two  years  and  a  half  old  generally  all  the  de- 
ciduous teeth  have  appeared.  Two  of  the  inferior  incisors  appear 
first,  then  the  four  upper  incisors,  followed  by  the  remaining  two 
below.  Very  soon  after  the  eruption  of  the  last  already  mentioned, 
the  growth  of  four  jaw  teeth  becomes  evident  by  the  fulness  and 
tenderness  of  the  gums  at  the  point  where  they  will  ultimately  ap- 
pear. Should  the  child  survive  the  irritation  which  results,  at  the 
age  of  two  years  and  a  half  four  more  jaw  teeth  should  be  cut, 
which  make  twenty.  They  are  called  deciduous  because  they  are 
displaced,  and  very  soon  others  appear,  which  may  decay  and  dis- 
appear very  soon,  or  they  may  remain  and  perform  their  function 
for  fourscore  years.  At  the  age  of  maturity,  every  human  being 
should  have  thirty-two  teeth.  All  of  this  you  can  learn  from  the 
professors  of  anatomy  and  obstetrics.  But  the  question  that  now 
arises  is,  what  is  the  best  method  of  preserving  teeth?  When  the 
permanent  front  teeth  appear,  they  should  be  polished  with  pumice- 
stone.  Take  a  piece  of  rattan  or  white  pine,  whittle  it  into  the  shape, 
or  rather  the  width  of  a  tooth,  wet  it  with  water,  dip  it  into  a  box 
containing  pumice-stone,  and  by  gentle  friction  you  can  remove  the 
natural  roughness  of  the  tooth,  which  causes  it  to  decay.  Sugar 
adheres  to  the  rough  surface,  and  is  converted  into  lactic  acid, 
which  will  destroy  the  enamel.  By  the  application  of  pumice-stone 
the  tooth  is  polished,  nothing  can  adhere  to  produce  a  destruction 
of  the  enamel,  and  consequently  the  teeth  will  not  decay,  provided 
they  are,  after  every  meal,  washed  with  cold  water,  and  rubbed 
with  a  wet  towel  wrapped  around  the  forefinger.  My  father  died 
at  the  age  of  eighty ;  he  had  not  a  decayed  tooth,  had  never  used 
a  tooth-brush,  but  always  after  every  meal  he  went  to  the  wash- 
stand,  wrapped  a  towel  around  the  forefinger  of  the  right  hand, 
dipped  it  into  a  basin  of  water,  and  rubbed  his  teeth  until  they 
were  thoroughly  cleaned. 

Every  child  must  be  forced  to  take  food  that  contains  phosphates, 
or  the  bone-making  material,  and  then  the  teeth,  even  the  first,  will 
be  large  and  strong,  and  the  second  will  be  so  perfect  that  with  the 
use  of  a  soft  brush  covered  with  Windsor  soap,  or  a  solution  of  bi- 


372  LECTURES    ON    PRACTICAL    SURGERY. 

carbonate  of  potash  or  soda,  will  cleanse  the  teeth  without  proving 
injurious  to  the  enamel.  A  stiff  tooth-brush  should  never  be  used. 
Professor  Dudley  recommended  the  students  to  use  strong  brushes. 
I  followed  his  instructions,  and  very  soon  found  that  my  teeth  were 
gumless.  I  was  compelled  to  abandon  the  stiff  brush.  If  I  had  not 
I  now  would  not  have  a  single  natural  tooth.  Always  use  a  soft 
brush,  or  a  cloth  wrapped  around  the  forefinger;  have  the  teeth,  when 
they  are  young,  polished  with  pumice-stone.  It  sometimes  be- 
comes necessary  to  extract  the  teeth,  because  they  are  so  much  de- 
cayed that  they  cannot  bear  a  plug,  and  after  the  tooth  is  extracted, 
haemorrhage  may  follow,  which  you  should  know  how  to  arrest. 
Take  a  narrow  strip  of  wet  lint,  covered  with  MonsePs  salt,  pass  it 
into  the  cavity  left  by  the  removal  of  the  tooth,  and  force  it  firmly, 
and  retain  it  a  few  minutes  by  pressure,  and  the  patient  will  be  re- 
lieved. A  great  many  of  the  common  people  never  wash  their  teeth 
when  perfectly  sound,  and,  in  consequence,  have  an  accumulation  of 
what  is  called  tartar,  which  separates  the  gums  from  the  teeth ;  the 
latter  fall  out,  and  the  parasites  disappear  when  the  accommodations 
are  diminished.  They  cannot  live  without  nutriment,  and  in  such 
mouths  they  find  all  they  need  as  long  as  the  filthy  teeth  remain. 


LECTURE    XXXV.  —  CONCUSSION    OF    THE    BRAIN.  373 


LECTURE    XXXV. 


GENTLEMEN  :  To-day  I  propose  to  lecture  on  the  injuries  of  the 
brain,  spinal  cord,  and  nerves. 

Concussion  is  a  violent  shock  which  may  injure  either  the  mem- 
branes or  the  cerebral  substance  itself.  They  may  be  either  lacerated 
or  their  vital  action  disturbed.  In  some  cases  both  conditions  exist, 
and  may  be  followed  by  inflammation.  Concussion  may  result  from 
either  a  fall  or  a  blow  upon  the  head.  The  symptoms  vary,  of 
course,  according  to  the  extent  of  the  injury.  I  intend  to  illustrate 
what  I  have  to  say  by  cases,  having  had  three  or  four  recently  which 
will  enable  me  to  explain  the  peculiarities  of  each  variety.  Some 
years  ago  I  was  superintending  the  erection  of  a  quartz-mill,  in 
Calaveras  County,  for  a  friend.  Being  in  want  of  some  materials  to 
continue  the  work,  it  became  necessary  that  I  should  go  to  Moque- 
lumne  Hill.  I  mounted  a  mule  that  had  not  been  saddled  for  several 
months,  and  I  wore  a  pair  of  Mexican  spurs.  Having  dropped  the 
reins  to  put  on  my  gloves,  I  suppose  the  spurs  touched  the  mule's 
sides,  and  she  commenced  bucking,  as  it  is  called  by  the  Californians. 
I  caught  the  reins,  and  they  broke,  and  I  fell  backwards  on  a  small 
stump,  about  four  feet  from  the  mule.  I  recollect  regaining  my 
feet,  but  was  not  conscious  of  anything  that  occurred  until  I  was 
about  two  hundred  yards  from  where  the  accident  occurred.  I  was 
sitting  near  the  road  upon  a  rock  of  granite.  How  long  I  had 
occupied  that  position  I  am  unable  to  say,  and  only  became  conscious 
after  having  my  face  and  head  bathed  with  cold  water  by  one  of  the 
miners  in  my  employ.  The  shock  was  slight;  the  function  of  the 
brain  was  only  disturbed,  without  any  organic  lesion.  After  becom- 
ing conscious  I  had  a  fine  donkey  saddled,  rode  to  Moquelumne 
Hill,  and  transacted  my  business  as  well  as  if  the  accident  had  not 
occurred,  but  was  confined  to  bed  for  a  week  in  consequence  of  the 
contusion  I  received  by  the  fall.  I  have  described  the  slightest  form 
of  concussion,  which  is  only  a  disturbance  which  produces  a  tempo- 
rary cessation  of  the  function  of  the  brain  ;  sometimes  the  violence 


374  LECTURES    ON    PRACTICAL    SURGERY. 

offered  is  greater,  and  the  insensibility  may  last  for  several  hours;  in 
this  case  the  return  of  consciousness  is  almost  always  accompanied 
by  vomiting,  which  should  be  regarded  as  very  favorable.  I  have 
seldom  lost  a  case  in  which  consciousness  returned  in  three  or  four 
hours  after  the  receipt  of  the  injury.  I  have  endeavored  to  describe 
the  symptoms  you  may  expect  to  find  in  cases  where  there  is  simple 
concussion.  When  the  injury  is  more  serious,  the  state  of  insensi- 
bility remains,  and  the  vomiting  sometimes  becomes  very  distressing. 
I  recollect  the  case  of  a  boy  about  ten  years  old,  who  fell  from  a 
piazza  fifteen  feet  high,  and  struck  his  head  upon  a  brick  pavement; 
he  was  insensible  about  twelve  hours.  I  gave  him  ten  grains  of 
calomel,  which  was  the  best  remedy  he  could  have  taken  under  the 
circumstances.  Cold  applications  were  made,  and  when  the  calomel 
acted  he  became  conscious  and  recovered  rapidly.  This  was  a  more 
violent  concussion.  About  two  years  ago  I  was  called  to  see  a  female 
child  about  seven  years  old.  She  had  been  for  some  time  in  the 
habit  of  ascending  the  stairs  on  the  outside  of  the  railing.  Although 
she  was  very  active,  on  one  occasion  she  fell  about  fifteen  feet,  and 
her  head  struck  upon  a  mat  that  was  in  the  passage.  She  was  taken 

x  r^  o 

to  bed  in  a  state  of  insensibility.  I  was  called  soon  after  the  acci- 
dent, and  found  her  pulse  very  quick  and  small.  The  breathing 
was  sometimes  very  rapid  and  irregular,  and  sometimes  very  slow ; 
the  extremities  were  cold,  the  patient  was  entirely  insensible,  and 
the  body  was  in  constant  motion.  She  was  not  only  insensible,  but 
was  unable  to  take  either  food  or  medicine.  Bottles  filled  with  hot 
water  were  applied  to  the  feet  as  well  as  to  the  entire  body.  She  re- 
mained insensible  from  five  o'clock  in  the  afternoon  until  eleven  at 
night.  Consciousness  then  returned,  with  violent  reaction ;  the  body 
was  hot,  the  pulse  full  and  quick,  and,  to  prevent  inflammation,  I 
opened  a  vein  in  the  arm  and  abstracted  at  least  a  pint  of  blood ; 
then  I  prescribed  my  depressant  mixture,  and  continued  it  until  the 
danger  of  inflammation  had  passed.  I  gave  after  venesection  a  strong 
mercurial  cathartic,  followed  by  the  depressant  already  mentioned. 
Always  after  such  injuries  give  calomel,  at  first  in  purgative  doses, 
and  then  keep  the  liver  acting  by  giving  two  grains  of  the  ext. 
juglandis  at  night,  so  as  to  prevent  abscess  of  the  liver,  which  is 
always  a  serious  complication. 

This  was  a  case  of  violent  concussion  of  the  brain,  which  would 
have  proved  fatal  if  it  had  not  been  treated  so  actively.     This  child 


LECTURE    XXXV.  —  CONCUSSION    OF    THE    BRAIN.  375 

was  not  allowed  to  leave  the  house  for  four  weeks,  and  was  not  ex- 
posed to  any  kind  of  excitement.  In  the  case  of  the  child  of  Mr.  W., 
of  this  city,  I  thought  there  was  laceration  of  the  brain.  The  child 
was  six  or  seven  years  old,  and  fell  from  a  back  piazza  upon  a  brick 
pavement  about  fifteen  feet  below.  She  was  taken  up  in  a  state  of 
insensibility;  began  to  vomit  in  twenty  or  thirty  minutes,  very  soon 
became  conscious,  and  from  that  time  presented  the  following  symp- 
toms :  She  had  some  fever  every  afternoon ;  her  cheeks  were  flushed. 
Light  and  noise  distressed  her  greatly.  The  skin  was  dry  and  hot, 
and  the  tongue  coated ;  there  was  an  entire  loss  of  appetite,  accom- 
panied with  constipation.  As  the  disease  progressed  she  became 
delirious,  and  the  action  of  the  carotid  arteries  was  greatly  increased. 
Convulsions  finally  appeared,  accompanied  with  paralysis  of  one  side 
of  the  body.  She  was  leeched;  took  the  depressant  mixture  to 
control  the  fever.  Blisters  were  applied  behind  the  ears ;  alcohol 
and  water  to  the  head.  Indeed,  everything  which  I  thought  could 
benefit  the  patient  was  done,  but  only  with  a  temporary  effect.  The 
post-mortem  examination  proved  that  the  brain  was  softened,  and 
the  disorganized  mass  was  mixed  with  blood  and  purulent  matter. 
The  membranes  were  lacerated,  preternaturally  vascular,  and  covered 
with  plastic  lymph.  In  such  cases  you  should  always  be  careful  in 
your  prognosis.  Any  physician  who  was  not  aware  of  the  insidious 
character  of  such  injuries,  would  have  pronounced  the  child  safe  so 
soon  as  consciousness  was  restored.  I  told  the  parents  that  she  was 
greatly  in  peril,  and  could  not  be  regarded  as  safe  until  the  expira- 
tion of  five  weeks.  I  would  have  pursued  the  same  course  in  this 
that  was  adopted  in  the  preceding  case,  if  she  had  not  been  greatly 
debilitated,  when  the  injury  was  received,  by  a  severe  attack  of  the 
measles.  After  any  injury  of  this  character,  when  the  pulse  becomes 
quick  and  full,  the  only  remedy  that  will  control  the  difficulty  is  the 
lancet;  and  if  you  intend  to  abstract  blood,  do  not  postpone  the 
operation.  Relieve  the  injured  vessels;  this  will  afford  time  by 
depressants  to  prevent  any  subsequent  difficulty;  if  they  are  not 
sufficient  to  obviate  the  continuance  of  the  inflammation,  apply 
leeches  behind  the  ears.  They  should  be  followed  by  blisters,  and 
especial  attention  should  be  paid  to  the  condition  of  the  digestive 
organs.  Calomel  and  the  extract  of  juglans  are  the  only  remedies 
which  rarely  fail  to  act  upon  the  liver. 

I  will  now  direct  your  attention  to  sanguineous  effusions  between 


376  LECTURES    ON    PRACTICAL    SURGERY. 

the  cranium  and  scalp.  This  difficulty  occurs  at  all  ages,  and  is  the 
result  of  violence.  The  tumor  becomes  sometimes  quite  large. 
They  sometimes  appear  in  children  two  or  three  days  after  delivery. 
In  such  cases  never  make  an  incision;  watch  and  wait,  and  if  sup- 
puration takes  place,  which  can  be  ascertained  by  the  use  of  an 
exploring  needle,  make  an  incision.  Insert  a  tent,  and  afterwards 
treat  the  case  as  an  ordinary  abscess.  If  you  make  an  incision  to 
evacuate  the  contents  of  such  tumors,  a  troublesome  haemorrhage 
may  follow.  If,  however,  sufficient  time  is  allowed  for  the  mouths 
of  the  wounded  vessels  to  close,  and  the  escape  of  blood  to  cease, 
then  if  the  contents,  that  is  those  that  can  be  absorbed,  do  not  dis- 
appear, an  incision  should  be  made  and  the  same  course  pursued  as 
when  effusions  of  blood  take  place  from  injuries  of  any  other  char- 
acter. Should  the  effusion  be  great,  inflammation  of  the  sac  which 
contains  the  blood  will  take  place,  pus  will  form,  and  if  not  opened 
with  a  lancet  or  bistoury,  will  cause  ulceration  by  pressure,  and  the 
contents  of  the  abscess  will  be  discharged.  The  discharge  will  con- 
tinue until  granulations  fill  the  cavity  and  cicatrization  is  complete. 
Compression  of  the  brain  results  either  from  effusion,  or  depression 
of  the  cranium,  and  the  effect  depends  upon  the  extent  of  the  cause. 
The  paralysis  takes  place  on  the  opposite  side  from  that  receiving 
the  injury,  in  consequence  of  the  nerves  crossing  at  the  base  of  the 
brain.  Effusion  may  be  either  primary  or  secondary;  if  the  injury 
be  sufficiently  violent  to  open  a  large  vessel,  the  blood  escapes  at 
once,  and  then  you  have  the  symptoms  of  sanguineous  effusion.  They 
are  more  or  less  insensibility,  accompanied  with  paralysis  of  the 
opposite  side  of  the  body.  Should  a  patient  receive  a  blow  and 
become  suddenly  paralyzed,  it  is  positive  evidence  that  there  is 
pressure  upon  the  brain,  which  must  be  produced  either  by  extrava- 
sated  blood  or  by  fracture  and  depression  of  the  bone.  A  great 
amount  of  pressure  is  not  necessary  to  produce  this  effect.  Many 
years  ago,  after  removing  a  depressed  portion  of  bone  in  a  case  of 
epilepsy,  I  pressed  gently  with  my  forefinger  upon  the  dura  mater, 
and  the  boy  became  insensible;  but  so  soon  as  the  pressure  was 
removed  consciousness  returned,  showing  how  slight  a  pressure  was 
required  to  produce  paralysis.  Effusion  may  be  either  primary  or 
secondary.  Should  a  patient  become  insensible  soon  after  the  receipt 
of  an  injury,  and  remain  in  that  condition,  it  is  called  primary. 
Should  he  be  injured,  and  recover  from  the  injury  sufficiently  to 


LECTURE    XXXV.  —  COMPRESSION    OP    THE    BRAIN.         377 

walk  and  converse  intelligently  for  an  hour  or  two,  and  then  become 
stupid,  and  the  stupor  gradually  increase  until  be  becomes  insensible; 
in  that  case  the  effusion  is  secondary.  In  the  secondary  form  of 
effusion  the  vessel  wounded  is  probably  not  large,  the  blood  escapes 
slowly  into  the  cavity  of  the  cranium,  and  the  symptoms  of  the  com- 
pression do  not  appear  until  a  sufficient  quantity  has  escaped  to 
produce  that  effect.  In  such  cases,  where  the  extra  vasated  blood  is 
small  in  quantity,  the  effect  is  not  alarming,  as  there  is  merely  a 
numbness  or  slight  feebleness,  which  may  continue  for  a  time,  but  so 
soon  as  the  serum  of  the  blood  effused  is  absorbed,  the  brain  is  par- 
tially relieved,  and  becomes  accustomed  to  the  pressure,  accommo- 
dates itself  to  the  situation,  and  consequently  very  little  inconvenience 
is  experienced  from  the  difficulty,  yet  I  must  say  that  whenever 
paralysis  is  produced  by  sanguineous  effusion  the  consequences  can 
never  be  entirely  removed. 

When  the  effusion  is  very  great,  and  one  side  of  the  body  is  per- 
fectly paralyzed,  the  patient  will  remain  in  that  condition  for  two  or 
three  weeks ;  the  speech  may  be  partially  restored,  but  recovery 
never  ensues.  Sometimes  you  will  read,  in  a  medical  journal,  of 
paralysis  being  cured  by  quinine  and  strychnine.  The  author  of 
such  articles  I  always  regard  as  either  a  knave  or  fool,  and  am  chari- 
table enough  to  think  that  he  is  a  fool. 

Whenever  you  are  called  to  a  patient  with  paralysis  of  half  of 
the  body,  if  there  does  not  exist  a  depression  of  the  cranium,  always 
say  to  the  friends  of  the  patient  that  the  case  is  incurable.  Tell 
them  that  he  will  gradually  improve,  but  he  never  can  recover. 
Then  a  consultation  will  either  be  called,  or  you  will  be  discharged, 
either  of  which,  unless  your  patient  is  very  rich,  should  not  be  re- 
gretted. A  gentleman  of  this  city,  forty-eight  years  old,  who  was 
wealthy,  and  intemperate  in  every  respect,  was  returning  one  day 
from  his  office,  when  he  had  an  attack  of  apoplexy.  His  right  side 
was  paralyzed,  he  lost  the  power  of  speech,  and  I  told  his  wife  he 
could  never  recover  entirely,  and  if  a  consultation  was  desired  I  would 
meet  the  physicians  he  preferred.  At  ten  o'clock  A.M.  we  met.  I 
had  a  dozen  leeches  applied  behind  the  ears,  followed  by  blisters, 
laxatives,  and  a  proper  diet,  and  as  he  had  been  an  epicure,  I  di- 
rected the  nurse  to  give  him  four  or  five  glasses  of  old  Bourbon  in 
twenty-four  hours.  The  physicians  came,  and  said  that  they  could 
not  suggest  anything  better  than  what  I  had  prescribed.  The  effu- 


378          LECTURES  ON  PRACTICAL  SURGERY. 

sion  was  not  sufficient  to  destroy  life,  but  only  the  sensibility  and 
motion  of  one  side  of  the  body  were  impaired.  This  patient,  who 
was  rich,  when  he  partially  recovered  the  use  of  the  lower  extremity, 
and  could  with  difficulty  mount  a  horse,  rode  to  the  Cliff  House 
often.  Subsequently  he  rode  in  a  sulky,  without  springs,  to  the 
Cliff  and  Ocean  Houses  and  back,  and  enjoyed  the  ride.  Being  an 
epicure  in  every  particular,  very  soon  he  had  a  second,  third,  and 
fourth  attack,  which  ended  in  mental  derangement.  He  was  then 
sent  to  a  private  insane  asylum  in  Alameda. 

Both  the  mania  and  paralysis  continued  for  two  years,  and  the 
patient  died  both  epileptic  and  paralyzed,  in  consequence  of  exces- 
sive eating,  which  will,  even  without  the  use  of  stimulants,  produce 
consequences  as  serious  as  those  caused  by  the  excessive  use  of  alcohol. 
Becoming  disgusted  with  the  physicians  of  this  city,  he  went  to  New 
York,  Baltimore,  Boston,  Philadelphia,  and  Albany.  He  received 
neither  encouragement  nor  relief,  and  then  he  determined  to  go  to 
Europe,  and  consult  all  celebrated  men  in  London,  Paris,  Edin- 
burgh, Vienna,  and  indeed  all  the  celebrities  of  Europe.  He  re- 
turned, after  an  absence  of  a  year,  in  the  same  condition  as  when  he 
left,  and  probably  not  quite  so  well.  He  then  discarded  all  the  med- 
ical practitioners  of  the  city,  and  employed  every  quack  who  exhib- 
ited a  sign.  He  took  tar-baths,  sulphur-baths,  and  ultimately  em- 
ployed a  Sandwich  Islander  to  lomi-lomi  him.  As  I  predicted  at 
the  commencement  of  the  difficulty,  the  disease  proved  to  be  incur- 
able, and  if  he  had  taken  my  advice  he  would  have  suffered  less, 
and  would,  when  he  returned,  have  been  in  better  health  than  when 
he  left. 

There  are  men  who  cannot  resist  the  fascinations  of  the  genuine 
charlatan.  Mystery  is  attractive,  and  now  I  advise  you  never  to 
tell  the  patient  what  medicine  he  is  taking.  An  old  pioneer,  and  one 
who  was  popular  when  I  arrived,  always  told  his  patients  what  med- 
icines he  administered,  and  after  a  time  he  lost  his  practice,  because 
his  patients  had  no  confidence  in  the  medicines  he  prescribed. 

When  a  man  in  good  health  falls,  and  remains  in  a  state  of  more 
or  less  insensibility,  that  condition  is  called  apoplexy.  I  have  already 
considered  this  difficulty,  and  will  not  recapitulate.  When  the  skull 
is  fractured  and  depressed,  accompanied  by  paralysis,  the  portion  of 
the  cranium  which  presses  upon  the  brain  should  be  raised  by  making 
an  opening  near  the  depressed  portion,  and  with  an  elevator  prying 


LECTURE    XXXV. — TUMORS    OF    THE    BRAIN.  379 

it  up  until  it  occupies  its  natural  position  ;  and  then  treat  the  case  on 
general  principles.  When  a  depression  of  a  portion  of  the  cranium 
exists,  but  the  patient  retains  his  consciousness,  there  is  no  propriety 
in  any  operation,  as  it  complicates  the  difficulty.  I  recollect  several 
cases  of  this  character  which  I  treated  with  success.  A  child  three 
or  four  years  old  was  kicked  by  a  mule ;  the  calk  of  the  hind  shoe 
struck  the  centre  of  the  forehead  just  above  the  root  of  the  nose, 
fracturing  the  skull  and  lacerating  the  longitudinal  sinus.  I  found 
it  impossible  to  raise  the  depressed  bone,  in  consequence  of  the  profuse 
discharge  of  blood  that  followed  the  slightest  disturbance  of  the  de- 
pressed portion.  The  child  had  convulsions  for  four  or  five  days, 
finally  became  conscious,  and  ultimately  recovered  ;  and  when  six  or 
seven  years  old  he  was  as  bright  as  any  other  child  of  the  same  age. 
He  is  now  living  in  Philadelphia,  and  well. 

Tumors  sometimes  form  on  the  brain,  and  produce  the  same  symp- 
toms. Such  cases  are  incurable.  In  cases  of  tertiary  syphilis,  nodes 
frequently  form  on  the  inside  of  the  cranium,  and  produce  the  same 
symptoms  as  those  which  result  from  effusion  of  blood,  and  these 
are  the  only  cases  that  are  curable.  Give  antisyphilitic  remedies, 
generous  diet,  and  in  some  cases  stimulants,  and  after  a  few  weeks 
the  paralysis  diminishes.  I  see  almost  every  day  a  man  who  had 
primary,  secondary,  and  tertiary  symptoms,  who  was  almost  entirely 
paralyzed  on  one  side,  and  complained  of  a  want  of  sensibility  on 
the  other,  who  recovered  entirely,  and  has  been  well  for  six  or  eight 
years. 

The  most  common  variety  of  tumor  found  in  the  brain  is  tuber- 
culous. Very  often  tubercles  form  in  the  brain  of  young  children ; 
they  suffer  more  or  less  until  insensibility  or  convulsions  occur,  and 
then  death  soon  follows.  In  such  children  hydrocephalus  frequently 
appears,  and  as  far  as  I  have  been  able  to  ascertain,  not  a  single 
positive  cure  has  been  effected.  In  such  cases  the  head  enlarges 
steadily,  until  it  sometimes  becomes  enormous.  As  I  said  before, 
this  always  proves  fatal.  The  spinal  cord  is  liable  to  both  concus- 
sion and  laceration.  When  concussion  of  the  cord  occurs,  tempo- 
rary paralysis  exists  below  the  seat  of  the  injury  ;  but  when  there  is 
a  laceration  of  the  cord,  paralysis  occurs,  and  that  is  always  perma- 
nent. Some  years  ago,  the  son  of  the  captain  of  a  clipper  ship  from 
Boston,  fell  from  the  mainyard  to  the  deck,  and  unfortunately  struck 
upon  a  rope  as  thick  as  a  man's  arm  ;  the  spine  was  fractured,  and  the 


380  LECTURES    ON    PRACTICAL    SURGERY. 

lower  extremities  completely  paralyzed.  He  had  retention  of  urine, 
and,  of  course,  constipation.  I  taught  the  father  how  to  use  the 
catheter ;  I  directed  him  to  procure  an  air-bed,  and  in  two  or  three 
weeks  he  left  this  port  for  Boston ;  his  son  arrived  there  without 
bed-sores,  and  three  years  after  the  accident  occurred  the  father  re- 
turned, and  called  upon  me  to  say  that  his  son  was  in  the  Marine 
Hospital  of  Boston,  was  in  good  health,  but  could  not  use  his  lower 
extremities.  In  this  case  the  bone  was  fractured,  and  the  spinal  cord 
lacerated. 

Concussion  of  the  spinal  cord  may  be  followed  by  inflammation. 
I  have  already  told  you  how  to  control  inflammation,  and  I  now  do 
not  consider  a  recapitulation  necessary.  Concussion  of  the  spinal 
cord  may  produce  only  temporary  inconvenience,  or  may  be  followed 
by  inflammation,  which  must  be  combated  by  the  proper  remedies. 

Before  closing  this  lecture,  I  will  consider  the  disease  called  spina 
bifida.  A  deficiency  of  bone  exists,  and  there  being  but  slight  resist- 
ance made  by  the  cutaneous  covering,  the  serum  accumulates  where 
the  least  resistance  is  offered.  A  tumor  forms  where  the  bone  is 
deficient,  and  soon  enlarges  so  much  that  the  skin  inflames,  and  when 
it  ulcerates,  inflammation  of  the  spinal  cord  extends  to  the  brain,  and 
very  soon  proves  fatal.  Dr.  Brainard,  of  Chicago,  recommended 
that  the  fluid  should  be  removed  by  the  use  of  the  trocar  and  canula, 
and  equal  parts  of  tinct.  iodine  and  water  should  be  injected  and 
allowed  to  remain  five  minutes,  and  then  permitted  to  escape.  I 
adopted  this  method  in  one  case  in  Green  Street.  The  tumor  disap- 
peared, but  the  child  never  recovered  the  use  of  the  lower  extrem- 
ities, and  died  in  a  few  months  from  cholera  infantum.  I  now  have 
a  case  of  spina  bifida,  and  when  the  operation  is  performed  will  notify 
the  class. 

When  a  nerve  is  divided,  or  when  strong  pressure  is  made,  as  by 
tumors  near  the  ear,  paralysis  of  one  side  of  the  face  occurs,  in  con- 
sequence of  the  facial  nerve  being  thereby  rendered  insensible.  When 
a  nerve  has  been  divided,  if  the  extremities  are  placed  in  contact 
they  will  unite,  and  the  function  of  the  nerve  be  restored.  Paralysis 
of  the  face  is  generally  preceded  by  pain  in  the  vicinity  of  the  ear. 
It  disfigures  the  face,  and  you  should  not  expect  immediate  relief. 
Apply  half  a  dozen  leeches,  which  should  be  followed  by  croton  oil  or 
blisters,  to  be  continued  until  the  difficulty  disappears.  The  general 
treatment  should  of  course  depend  upon  the  condition  of  the  patient. 


LECTURE  XXXV. — WOUNDS  OF  NERVES.        381 

When  a  nerve  is  wounded,  it  should  be  divided  above  the  seat  of 
the  injury,  and  at  least  half  an  inch  removed,  in  order  to  prevent 
the  union  of  the  extremities  and  the  return  of  the  symptoms.  I 
treated,  when  I  was  very  young,  a  negro  boy,  who  had,  some  weeks 
before,  his  uluar  nerve  wounded  by  the  saws  of  a  cotton  gin.  The 
power  of  the  hand  was  destroyed ;  it  was  cold.  He  had  difficulty 
in  deglutition,  and  the  power  of  speech  was  lost.  At  first  I  applied 
the  actual  cautery,  as  recommended  by  Jobert,  of  Paris.  The  symp- 
toms disappeared,  and  he  seemed  to  be  perfectly  well  for  two  or  three 
months,  when  the  symptoms  returned,  and  then  I  concluded  to  re- 
move a  portion  of  the  ulnar  nerve.  The  operation  was  performed 
above  the  wrist;  half  an  inch  of  the  nerve  was  removed;  the  wound 
healed  rapidly,  the  symptoms  of  chronic  tetanus  disappeared,  and  in 
two  months  he  was  as  well  as  any  man  in  the  State. 

Occasionally  a  nerve  is  wounded,  either  by  a  nail,  a  fall,  or  a  gun- 
shot wound.  When  produced  by  the  former,  enlarge  the  opening, 
fill  the  wound  with  cotton  or  lint  saturated  with  ol.  terebinthinse ; 
let  it  remain  for  three  or  four  days,  and  then  the  ulcer  should  be 
treated  as  any  other  of  a  simple  character.  Tetanus  may  result  from 
the  most  simple  wound,  and  when  it  does  occur,  if  it  be  possible, 
the  nerve  should  be  divided  between  the  seat  of  the  injury  and  the 
brain.  If  this  is  impossible,  you  must  rely  upon  the  local  applica- 
tion of  sulph.  morphia,  and  the  use  of  the  tinct.  of  cannabis  indica 
internally,  twenty  drops  every  two  hours,  until  the  symptoms  disap- 
pear. Tumors  or  enlargements  of  the  nerves  were  considered  when 
lecturing  on  tumors,  and  will  not  be  referred  to  again. 


382  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE    XXXVI. 

GENTLEMEN  :  To-day  I  will  lecture  on  the  diseases  of  the  mamma 
or  breast. 

Each  of  these  organs  is  composed  of  twelve  glandular  bodies, 
which  are  intended  to  secrete  milk,  for  a  special  purpose.  They  are 
so  liable  to  disease,  and  their  diseases  are  so  numerous,  that  for  con- 
venience they  should  be  classified.  1st.  I  will  mention  the  derange- 
ment of  the  nutritive  and  sensitive  action,  which  causes  pain  and 
enlargement;  the  2d,  includes  those  in  which  there  is  a  collection  of 
purulent  matter.  3d.  The  third  includes  morbid  growths,  which 
are  limited  to  the  part  in  which  they  originate.  4th.  Includes 
tumors  of  a  malignant  character,  which  have  a  tendency  to  spread, 
fungate,  ulcerate,  and  derange  the  constitution. 

I  beg  leave  now  to  direct  your  attention  to  excoriations  and  ulcera- 
tions  of  the  nipple.  You  will  find  in  practice  that  they  are  more 
troublesome  than  any  other  simple  disease  with  which  you  will  have 
to  contend.  If  proper  precautions  are  not  taken  before  delivery,  and 
often  under  any  circumstances,  the  nipple  inflames,  the  mucous 
membrane  is  either  detached  or  ulcerated,  and  every  time  the  child 
attempts  to  nurse,  excessive  pain  is  produced.  Sometimes  in  cases 
of  ulceration,  I  have  seen,  in  despite  of  treatment,  the  ulceration  ex- 
tend until  the  entire  nipple  was  destroyed.  Almost  every  nurse  and 
physician  you  meet  has  a  different  remedy;  and  I  have  always  found 
that  when  a  great  many  remedies  are  recommended  for  the  same 
disease,  you  may  be  assured  that  none  of  them  have  the  desired 
effect.  I  have  been  troubled  more  by  this  disease  than  by  any  other  I 
have  ever  treated.  Some  use  the  mucilage  from  quince-seeds.  Some 
use  glycerin  and  gum  arabic.  I  have  sometimes  used  glycerin  and 
alum,  five  or  ten  grains  of  the  latter  to  the  5j.  It  soothes  and  at  the 
same  time  hardens  the  mucous  membrane,  diminishes  the  irritability, 
and  lessens  the  pain. 

The  most  effectual  remedy,  when  fissures  or  ulcerations  exist,  is  to 
apply  the  nitrate  of  silver  in  substance;  wash  it  off  in  a  few  minutes, 


LECTURE    XXXVI.  —  DISEASES    OF    THE    BREAST.  383 

then  apply  simple  cerate  or  glycerin ;  some  prefer  the  sulphate  of 
copper,  but  from  experience  I  am  satisfied  that  the  escharotic  before 
named  is  far  superior,  and  relieves  pain  more  speedily  and  effectually. 
Some  nurses  use  Russian  salve,  and  I  must  confess  that  in  some  bad 
cases  the  effect  has  far  surpassed  my  expectations,  and  it  does  not 
injure  the  child.  When  the  patient  is  unwilling  to  have  the  caustic 
applied,  I  prescribe  the  tinct.  of  catechu.  It  is  a  good  application, 
and  the  nipples  should  be  wet  so  soon  as  the  child  has  nursed.  A 
child  should  not  be  nursed  oftener  than  every  three  hours,  and 
should  not  be  allowed  to  take  the  same  breast  twice  in  succession. 
The  professor  of  obstetrics,  during  his  lectures  on  this  subject,  will 
give  you  more  information  than  it  is  possible  that  I  could  possess. 

The  derangements  of  nutrition  and  sensation  include  the  indura- 
tions that  occur  at  the  age  of  puberty,  and  during  the  first  months 
of  pregnancy.  Very  often  you  will  find  that  young  girls,  when  there 
is  some  derangement,  either  an  excess  or  diminution  of  the  menstrual 
discharge,  suffer  from  this  difficulty ;  but  the  pain  does  not  disappear 
when  the  discharge  ceases.  Dysmenorrhoea  often  exists  in  bad 
cases.  In  this  disease  excessive  pain  occurs,  and  sometimes  continues 
for  twenty-four  hours  before  the  discharge  appears.  You  cannot 
expect  to  remove  the  effect  without  the  cause.  In  ordinary  cases  of 
dysmenorrhoaa,  tonics,  either  vegetable  or  mineral,  according  to  the 
condition  of  the  patient,  may  be  administered  with  great  advantage. 
I  find  that  the  tonic  mixture,  composed  of  senna,  nux  vomica,  aconite, 
and  hydrocyanic  acid,  is  generally  better  than  any  other  I  have  pre- 
scribed. There  are,  however,  other  combinations  of  remedies  which 
I  prescribe  in  anaemic  cases.  They  are  pale,  suffer  greatly  by  ascend- 
ing a  flight  of  stairs,  have  no  appetite,  and  the  feet  frequently  swell. 

ty.  Ferri  pulv.,  5iss. ;  gum  aloes  Soc.,  ext.  stram.,  aa  gr.  xv. 
Misce.  Fiant  pil.  No.  xxx.  Sig.  Take  one  three  times  a  day.  As 
a  soothing  application  to  the  breasts,  you  will  find  nothing  better 
than  the  extract  of  belladonna.  Take  of  the  extract  of  bella- 
donna, 5ij  ;  adipis  simplicis,  Sj.  Misce.  Sig.  Spread  upon  chamois 
leather,  cut  a  hole  for  the  nipple,  and  wear  it  constantly.  It  is 
harmless,  and  from  the  result  of  experience  in  such  cases,  I  am  satis- 
fied that  it  is  the  best  application  that  can  be  made.  Often  during 
the  first  months  of  pregnancy  the  breasts  become  painful,  they  swell, 
and  occasionally  suppurate.  I  have  treated  many  cases  of  this 
character,  and  the  difficulty  depends  upon  the  organs  engaged  in  the 


384  LECTURES    ON    PRACTICAL    SURGERY. 

same  function.  When  fluctuation  is  distinct,  open  the  abscess  and 
treat  it  as  I  directed  when  lecturing  on  ordinary  abscess.  Before  the 
abscess  forms,  and  when  suppuration  is  threatened,  apply  four  or  five 
double  of  flannel,  wet  with  hot  vinegar,  which  should  be  covered 
with  oiled  silk;  apply  morning  and  evening,  and  continue  until  the 
swelling  either  disappears  or  a  collection  of  matter  is  detected.  Then 
the  abscess  should  be  opened. 

The  second  variety  of  disease  of  the  breast  includes  cases  in  which 
there  is  a  collection  of  pus.  It  embraces  milk  abscess  and  chronic 
abscess.  After  confinement,  whether  a  woman  aborts  or  has  a  child 
at  the  ordinary  time,  on  the  third  day  what  is  called  the  milk  fever 
usually  appears.  The  breasts  swell,  the  secretion  of  milk  takes  place, 
and  if  the  case  is  properly  treated  an  abscess  seldom  forms.  I  have 
employed  three  nurses  in  this  city,  and  an  abscess  never  formed  in 
any  case  treated  by  them.  When  an  abscess  forms,  open  it  with  a 
lancet  or  bistoury;  insert  a  tent;  apply  mutton-suet  or  simple  cerate. 
Milk  fever  never  lasts  more  than  twenty-four  hours.  After  a  con- 
finement in  which  the  pain  continues  longer  than  the  time  specified, 
you  should  suspect  puerperal  peritonitis,  and  employ  the  remedies 
recommended  by  the  professor  of  obstetrics.  In  such  cases  opium  is 
the  sheet-anchor  of  success.  Sometimes  the  child  will  not  nurse, 
and  the  milk  must  be  removed  from  the  breast  with  a  pump  manu- 
factured for  that  purpose.  If  a  nurse  can  draw  the  breasts,  or  if  a 
child  or  children  in  the  neighborhood  can  be  obtained,  they  should 
be  preferred  to  a  pump.  Should  the  patient  be  able  to  find  some 
young  puppies,  if  their  feet  be  covered  with  cloth,  so  that  they  can- 
not scratch,  I  think  they  are  better  than  breast-pumps,  or  even  nurs- 
ing children  or  women.  When  the  breasts  are  greatly  enlarged,  and 
indurated  or  tense,  the  nipple  being  either  short  or  retracted,  great 
danger  exists  of  the  formation  of  an  abscess.  If  you  have  a  good 
nurse  there  is  but  little  danger;  they  generally  use  camphorated  oil, 
and  rub  the  breast  with  the  hands  from  the  nipple  backward  until 
milk  is  secreted.  The  friction  with  camphorated  oil  removes  the  accu- 
mulation of  the  blood,  and  when  the  quantity  is  reduced  to  the  secret- 
ing point,  the  formation  of  milk  takes  place.  A  first-class  nurse 
should  be  able  to  draw  the  breasts  herself,  or  to  adopt  the  means 
already  recommended  for  that  purpose.  Should  the  quantity  of  milk 
be  excessive,  and  the  nipples  sore,  have  a  belladonna  plaster  made 
of  5ij  of  the  extract,  and  hog's  lard,  Sj  ;  spread  this  upon  chamois 


LECTURE    XXXVI. DISEASES    OF    THE    BREAST.  385 

leather,  with  a  hole  for  the  nipple,  and  apply  it  to  the  entire  breast. 
Should  an  abscess  form,  the  sooner  you  open  it  the  better.  Some- 
times matter  forms  between  the  skin  and  mammary  glands;  the 
subcutaneous  cellular  tissue  is  destroyed,  and  an  immense  accumu- 
lation of  pus  takes  place  without  presenting  the  appearance  of  an 
ordinary  abscess.  Should  doubt  be  entertained  as  to  the  character 
of  the  difficulty,  use  the  exploring  needle,  and  then  make  a  free 
incision  ;  introduce  a  tent  to  prevent  union  by  the  first  intention, 
and  then  use  the  warm-water  dressing  until  the  opening  is  fully 
established.  With  ordinary  abscesses  of  the  breast  you  are  all 
familiar;  before  suppuration  takes  place  they  are  solid,  after  that 
occurs,  and  the  skin  becomes  red,  they  should  be  opened  and  treated 
as  already  indicated  ;  or,  if  very  painful,  an  incision  should  be  made 
so  soon  as  fluctuation  is  distinct.  We  often  find  in  cases  of  this 
character,  in  which  the  nipples  are  sore,  an  indurated  point  not  far 
from  the  nipple,  which  suppurates,  and  when  opened  soon  disap- 
pears. Such  an  abscess  is  superficial,  and  consequently  only  a  source 
of  inconvenience. 

This  division  includes  simple  vascular  sarcoma,  fibrous  and  cystic 
tumors.  They  do  not  spread  beyond  the  part  in  which  they  origi- 
nate. The  mammary  glands  may  become  enormously  enlarged,  or 
in  other  words  hypertrophied.  There  is  not  only  a  hypertrophy  of 
the  subcutaneous  cellular  tissue,  but  also  an  immense  enlargement 
of  the  glands.  I  recollect  an  old  lady,  the  most  celebrated  midwife 
in  the  country,  who  had  that  difficulty.  I  was  a  schoolboy,  and 
boarding  at  a  house  to  which  she  was  called  professionally.  Her 
breasts  were  so  long  when  not  bandaged  that  they  rested  upon  her 
thighs,  yet  she  was  active,  and  did  not  suffer  pain  nor  much  incon- 
venience from  the  enlargement.  In  this  locality  you  will  sometimes 
find  a  simple  encysted  tumor,  which  becomes  inconvenient  by  its 
size  and  weight,  and  should  be  removed.  Such  growths  are  always 
simple,  and  consequently  never  return.  Sometimes  fibrous  tumors 
form  in  the  breast;  they  may  be  known  by  their  firmness  and  smooth- 
ness, as  well  as  by  the  slowness  of  their  development.  They  should 
be  excised.  When  such  tumors  are  removed  early  and  carefully, 
they  rarely  return. 

I  am  sorry  that  I  cannot  say  as  much  for  the  fourth  variety,  which 
includes  carcinomatous  and  medullary,  or  cerebriform  tumors.  They 
are  almost  always  fatal,  yet  a  surgeon  is  sometimes  forced  to  operate 

25 


386  LECTURES    ON    PRACTICAL    SURGERY. 

during  the  early  stages  of  the  disease;  but  when  the  surrounding 
parts  are  implicated,  I  hope  you  will  pursue  the  course  which  I  have 
long  since  adopted.  Remove  a  scirrhus,  if  the  patient  consents,  before 
the  axillary  ganglions  become  implicated,  but  after  the  surrounding 
parts  become  involved,  prescribe  a  belladonna  plaster  and  some  tonic 
medicine.  She  will  not  return,  but  apply  to  some  young  man  who, 
to  obtain  notoriety,  will  remove  any  tumor  that  may  be  presented. 
In  a  few  weeks  the  tumor  returns,  another  is  employed,  and  the 
former  abused,  and  if  a  bill  is  presented  after  the  disease  returns, 
the  friends  not  only  refuse  to  pay  the  bill,  but  accuse  the  surgeon  of 
killing  the  patient,  in  which  they  are  often  encouraged  by  the  second 
physician  called.  Should  he  operate  a  second  time  in  two  or  three 
months,  the  disease  will  return,  and  in  a  few  days,  when  the  physi- 
cian visits  his  patient,  he  will  find  Li  Po  Tai  by  the  bedside,  and  the 
patient  is  happy;  but  that  condition  does  not  long  continue.  Pur- 
gation and  starvation  in  a  cachectic  condition  of  the  system  are  not 
conducive  to  longevity,  and  very  soon  you  will  be  required  to  sign 
the  certificate.  I  generally  send  the  applicant  to  the  city  physician. 
The  description,  history,  and  development  of  these  tumors  were  given 
in  my  lectures  on  tumors  delivered  some  months  since,  and  it  is  un- 
necessary now  to  detain  you  longer  on  this  subject ;  I  however  beg 
leave  to  say  that  whenever  you  decide  to  remove  a  tumor  of  this 
character,  be  careful  to  remove  the  entire  breast,  except  a  sufficiency 
of  the  skin  to  cover  the  wound,  and  that  should  be  healthy.  1  have 
had  a  case  recently  which  sustains  the  view  I  take  of  this  course  of 
treatment.  A  lady  from  Yisalia  applied  to  me  with  a  small,  hard 
tumor,  near  the  nipple,  which,  from  her  age,  I  thought  was  not 
malignant.  The  operation  was  confined  strictly  to  the  tumor.  She 
went  from  San  Francisco  to  Humboldt  County,  and  returned  to  San 
Francisco  at  the  expiration  of  a  year  with  a  tumor  ten  times  as  large 
as  the  one  removed.  I  then  removed  the  entire  breast,  the  wound 
healed  readily,  and  she  left  the  city  for  Sacramento.  She  returned 
to  this  city  recently,  a  year  having  elapsed  from  the  time  the  opera- 
tion was  performed,  perfectly  well.  After  a  careful  examination  I 
could  not  detect  the  slightest  evidence  of  a  return  of  the  disease,  and 
she  may  wholly  escape  it.  Sometimes,  after  a  malignant  tumor  has 
been  removed  from  the  breast,  it  does  not  return  in  the  part  in  which 
it  was  located,  but  forms  either  in  the  lungs,  the  pleura  costalis  or 
pulmonalis,  and  finally  proves  fatal.  The  patient  coughs  a  great 


LECTURE    XXXVI.  —  TUMORS    OF    THE    BREAST.  387 

deal,  expectorates  freely,  and  as  the  difficulty  of  breathing  increases, 
she  begins  to  emaciate,  and  is^soon  exhausted  by  the  expectoration, 
night-sweats,  and  especially  by  the  loss  of  appetite  and  digestion. 
Thirty  years  ago  a  lady  from  an  interior  small  town  visited  Colum- 
bia, South  Carolina,  with  what  I  thought  was  encephaloid.  A 
fungous  tumor  projected  above  the  skin,  as  large  as  a  man's  fist, 
from  the  external  surface  of  the  right  breast.  She  told  me  that 
she  came  to  have  it  removed,  and  desired  to  return  as  she  had  come, 
in  her  own  carriage,  in  three  days.  Her  general  health  seemed  to 
be  perfectly  good,  and  the  morning  after  her  arrival  the  tumor  was 
removed.  The  wound  was  closed  so  as  to  heal  by  the  first  intention, 
and  in  three  days  the  mother  of  Governor  Gist,  of  South  Carolina, 
left  Columbia,  reached  home  safely,  and  when  Dr.  Bobs,  who  is  now 
in  Marysville,  came  to  California,  he  told  me  that  Mrs.  Gist  was 
alive  and  well  with  the  exception  that  she  had  an  epithelioma  upon 
the  nose,  which  was  not  alarming  by  its  progress.  I  have  men- 
tioned these  cases  so  as  to  encourage  you  to  remove  a  tumor  a 
second  time,  when  the  adjacent  parts  are  not  implicated,  and  the 
cancerous  cachexia  has  not  appeared.  Many  talented  and  worthy 
young  men  take  desperate  cases;  but  no  matter  how  anxious  a 
physician  may  feel  to  operate,  he  should  select  a  case  in  which  a 
strong  probability  of  success  exists,  and  then  he  will  not  be  often 
disappointed.  When  a  breast  is  removed,  even  under  favorable  cir- 
cumstances, and  the  disease  returns,  the  parties  interested  will  always 
be  dissatisfied,  and  should  a  second  operation  be  required,  they  will 
employ  some  other  surgeon  to  perform  it,  unless  the  friends  are  suf- 
ficiently intelligent  to  resist  such  interference. 

I  recollect  that  about  ten  years  ago  a  young  lady  came  from 
Petaluma  with  an  encephaloid  of  one  of  her  breasts.  I  removed  it. 
She  returned  home,  and  in  three  or  four  months  she  came  to  the  city 
with  a  tumor  much  larger  than  the  original.  In  the  first  operation 
I  removed  the  axillary  ganglions.  The  axillary  artery  was  exposed 
for  several  inches,  and  I  dissected  the  diseased  mass  from  the  coats 
of  the  artery.  The  disease  returned,  and  a  few  months  ago  she 
employed  a  Frenchman  of  this  city  to  perform  a  second  operation, 
which  proved  fatal,  probably  from  hemorrhage.  In  ray  operations 
I  like  to  have  three  or  four  young  men  around  with  artery  forceps, 
and  then  I  am  fearless. 


388  LECTURES    ON    PRACTICAL.  SURGERY, 


LKCTUEi:   XXXVII. 

GENTLEMEN:  Before  I  endeavor  to  describe  the  various  diseases 
of  the  uterus,  I  beg  leave  to  say  a  few  words  in  reference  to-  the 
speculum^  which  is  the  instrument  used  for  the  purpose  of  exam- 
ining the  vagina  and  uterus.  The  best  form  of  the  instrument  is  a 
bivalve,  with- one  blade  longer  than  the  other.  I  have,  for  eight  or 
ten  years,  occasionally  used  one  of  large  size,  when  the  uterus  could 
not  be  exposed  by  the  ordinary  glass  instrument.  When  this  bi- 
valve speculum  is  introduced;  the  long  blade  should  be  turned 
posteriorly  so  as  to  receive  the  uterus  when  the  blades  are  sep- 
arated. This  instrument  fulfils  every  indication.  In  some  cases 
an  ordinary  small  bivalve  speculunr  is  more  convenient,  and  par- 
ticularly for  examining  the  vagina  and  urethra.  Many  prefer  a 
cylindrical  glass  speculum.  This  is  cheap,  exposes  the  os  uteri  ex- 
ceedingly well,  and  is  not  stained  by  the  use  of  the  nitrate  of  silver.. 
I  always  keep  four  or  five  of  them  in  my  office- of  different  sizes,  for 
sometimes  the  organs  are  so  irritable  that  a  very  small  speculum  be- 
comes necessary.  At  my  office  I  use  a  Chinese  chair,  place  the  pa- 
tient upon  the  back,  and  use  soap  for  the  purpose  of  lubricating  the 
instrument,  so  as  to  lessen  the  pain.  When  I  treat  ladies  at  home, 
they  generally  cover  themselves  with  a  sheet,  in  the  centre  of  which 
there  is  a  small  opening,  through  which  the  speculum  can  be  passed 
conveniently..  It  is  necessary  to  have  agood  light,  and  either  a  lounge, 
sofa,  or  bed  may  be  used.  When  the  preparations  are  neither  tedious- 
nor  extensive,  the  patient  submits  with  less  reluctance  to  an  exam- 
ination. You  should  become  familiar  with  the  use  of  the  female 
catheter.  I  have  frequently  met  physicians  in  consultation  who 
could  not  pass  a  catheter  without  exposing  the  patient.  But  if  you 
take  the  forefinger  of  the  left  hand,  and  pass  it  below  the  clitoris,  it 
will  come  in  contact  with  a  projection  which  is  the  female  urethra; 
The  catheter  should  be  guided  by  the  finger  to  that  point,  and  it 
will  readily  pass  into  the  bladder.  The  female  urethra  is  not  much 
more  than  an  inch  in  length,  and  unless  a  stricture  exists,  the- 
catheter  will  pass  without  any  difficulty.  When  the  female  urethra 


LECTU'RE    XXXVII.  —  DISEASES  -OF    LABIA.  (       389 

is  strictured,  I  generally  have  a  conical  bougie  straightened,  and 
passed  into  the  bladder,  and  allowed  to  remain  half  an  hour;  the 
operation  should  be  repeated  every  alternate  day  until  the  stricture 
is  cured.  In  a  remarkable  oase  of  stricture  of  the  urethra,  in  this 
city,  in  which  the  bladder  was  enormously  distended  by  constant  and 
continued  pressure,  I  passed  an  ordinary  female  catheter  into  the 
bladder;  the  operation  was  repeated  several  times,  when  the  patient 
resumed  her  former  course  *of  dissipation,  and  the  same  difficulty 
returned.  Some  physicians  were  called  to  see  her;  they  decided  to 
puncture  the  bladder,  and  she  died  of  peritonitis,  a  few  days  after 
the  .operation,  from  the  infiltration  of  urine.  It  is  always  safer 
to  force  the  catheter  or  bougie  through  the  urethra  than  to  puncture 
the  bladder,  which,  with  me,  kas  always  been  regarded  as  the  last 
resort,  and  an  operation  that  I  never  have  performed  but  once,  and 
with  a  satisfactory  result. 

The  external  organs  of  the  female  are  liable  to  various  diseases, 
such  as  hypertrophy,  cysts,  and  varicose  enlargement  of  the  veins. 
Very  frequently  you  will  find  a  patient  with  enlargement  and  in- 
duration of  the  labia,  preceded  by  inflammation,  which  is  often 
produced  by  excessive  indulgence.  When  fluctuation  becomes  evi- 
dent, the  abscess  should  be  opened  ;  should  it  return,  the  sac  should 
be  removed,  and  then  the  difficulty  will  be  finally  overcome.  I  have 
treated  many  cases  of  this  character,  and  one  case  in  which  an  abscess 
occurred  at  every  monthly  period,  which  I  cured  by  removing  the 
sac.  There  is  another  difficulty  which  frequently  exists,  and  that  is 
an  enlargement  of  the  veins  of  the  labia,  which  sometimes  becomes 
so  great  as  to  absolutely  prevent  coition.  This  enlargement  some- 
times involves  not  only  the  vagina,  but  also  the  vulva.  Sometimes 
the  veins  become  so  enlarged  that  they  yield  to  the  distension,  and 
nothing  but  pressure  will  arrest  the  haemorrhage.  The  female  organs 
of  generation,  particularly  when  there  is  a  discharge  of  mucus  from 
the  vagina,  are  affected  by  warty  excrescences  of  the  vulva.  Each 
wart  should  be  tied  with  a  separate  ligature,  if  possible,  and  when 
they  drop  off  they  will  never  return.  Warts  that  are  not  of  a  specific 
character  almost  always  result  from  inattention  to  cleanliness.  If 
they  do  not  disappear  after  the  application  of  MonsePs  salt,  and  are 
too  numerous  to  ligate,  these  -should  be  removed  with  scissors,  and 
the  MonsePs  salt  applied  every  day  until  the  parts  heal  entirely. 
Nsevus,  which  I  have  already  described,  sometimes  appears  in  the 


390          LECTURES  ON  PRACTICAL  SURGERY. 

labia.  This  difficulty  is  serious  in  proportion  to  the  size  of  the 
tumors;  when  small  they  may  be  excised,  when  large  a  ligature 
should  be  applied  subcutaneously,  as  described.  When  lecturing 
upon  this  subject  I  said,  Never  tie  the  skin,  because  tetanus  fre- 
quently results  from  so  doing.  After  the  separation  of  the  ligature, 
then  the  discolored  and  diseased  skin  should  be  removed. 

In  cystic  tumors  of  the  labia,  the  cyst  usually  contains  a  san- 
guineous or  turbid  fluid,  but  sometimes  you  will  find  a  wen,  all  the 
varieties  of  which  do  not  contain  the  same  substance,  but  require  the 
same  treatment.  They  should  be  removed,  and  you  must  remember 
that  haemorrhage  is  generally  more  profuse  after  operations  upon  the 
labia,  than  upon  any  other  portion  of  the  body.  Tie  every  vessel 
that  bleeds.  The  wound  should  not  be  closed  until  the  bleeding  has 
entirely  ceased,  and  then  if  not  near  the  residence  of  the  patient, 
apply,  or  at  least  prepare,  a  bandage  with  compresses,  jand  leave  di- 
rections how  they  should  be  applied,  with  a  compress.  A  bandage 
properly  applied  will  arrest  any  haemorrhage  that  may  result  from 
such  an  operation.  Even  in  uterine  haemorrhage,  the  tampon  and 
a  compress,  secured  by  a  T-bandage,  will  arrest  any  haemorrhage. 
Should  that  fail,  in  consequence  of  not  being  properly  applied,  re- 
move the  sutures,  open  the  wound,  apply  wet  lint  covered  with 
Monsel's  salt.  Dry  lint  should  be  placed  over  that,  and  secured  by 
the  T-bandage.  Sometimes  after  marriage  the  hymen  exists  and 
is  so  strong  that  sexual  intercourse  cannot  take  place.  In  such  cases 
give  chloroform,  introduce  the  forefinger,  and  rupture  the  hymen ; 
but  little  force  is  necessary.  We  are  called  upon  to  perform  this 
operation  very  seldom,  because  nearly  every  mother  who  discovers 
the  existence  of  this  membrane  goes  to  the  most  popular  physician 
in  the  vicinity  to  have  it  destroyed.  They  cannot  be  convinced 
that  it  is  natural,  and  demand  an  operation.  In  such  cases  I  pass 
an  ordinary  steel  director  through  the  small  opening,  at  the  upper 
edge  of  the  membrane,  when  in  a  recumbent  position,  and  with  that 
lacerate  the  hymen.  Then  when  the  mother  is  convinced  that  the 
obstruction  is  removed  she  is  perfectly  happy,  and  will  pay  more 
liberally  than  for  any  other  slight  operation  that  I  am  required  to 
perform.  I  operate  in  such  cases  for  the  relief  of  the  mother.  If 
I  refused  to  do  what  she  thought  should  be  done,  she  would  employ 
a  charlatan,  who  would  charge  two  or  three  hundred  dollars,  and 
probably  inflict  a  permanent  injury  upon  the  child.  It  is  by  all  na- 


LECTURE    XXXVII. —  DISEASES    OF    FEMALE    ORGANS.     391 

tions  regarded  as  a  positive  evidence  of  virginity,  even  among 
savages,  and  with  educated  people  I  can  very  soon  convince  them  of 
the  necessity  of  having  the  hymen  intact,  because  it  seldom  presents 
any  serious  obstacle  to  coition.  Strumous  children  have,  with 
ophthalmia,  a  discharge  from  the  vagina,  which  from  the  irritation 
and  the  itching  necessarily  resulting,  may  induce  the  destructive 
habit  of  masturbation.  To-day  I  saw  a  child  two  years  and  a  half 
old,  whose  hands  were  tied  for  the  purpose  of  stopping  that  indul- 
gence. I  cut  the  gums  covering  the  jaw  teeth,  gave  the  child  sul- 
phate of  quinine,  with  fluid  ext.  of  senna,  and  ordered  5iv  of  alum 
to  be  put  into  a  quart  of  water,  and  used  twice  a  day  with  a  syringe. 
A  few  days  since,  an  ignorant  woman  came  to  my  office  with  three 
female  children  ;  they  all  had  a  discharge  from  the  vagina;  one  of 
the  girls  was  three  years  old,  the  second  one  year  and  a  half,  and 
the  third  had  attained  the  age  of  six  months.  She  accused  a  lodger 
in  the  house  of  having  communicated  gonorrhoea  to  these  children. 
I  told  her  the  idea  was  ridiculous,  that  she  or  her  husband  was 
scrofulous,  and  that  it  was  necessary  that  they  should  take  medicine 
to  strengthen  them,  and  use  an  alum  wash. 

I  have  treated  a  very  extraordinary  case  in  this  city.  My  patient 
began  to  menstruate  at  the  age  of  twelve  years,  and  at  twenty-two 
she  had  a  long  spell  of  sickness ;  when  she  recovered,  the  menstrual 
flow  disappeared  entirely.  After  suffering  excessively  for  several 
days,  a  slight  discharge  of  blood  would  escape  from  the  rectum,  and 
the  womb  experienced  relief.  The  vagina  was  completely  closed, 
and  I  operated  in  the  presence  of  four  of  our  best  physicians,  reached 
the  uterus  without  wounding  either  the  rectum  or  bladder,  kept  the 
passage  from  closing  by  the  introduction  of  oiled  lint,  and  when  the 
next  menstrual  period  arrived,  she  did  not  experience  any  pain. 
Very  soon  she  became  pregnant,  and  I  delivered  her  of  a  dead  child 
with  forceps,  after  having  divided  with  the  scissors  the  bands  that 
had  formed  in  the  vagina  and  produced  the  difficulty.  Subsequently 
I  delivered  her  of  three  living  children.  This  case  was  published  at 
the  time  in  the  Pacific  Medical  Journal.  I  made  the  incision  trans- 
versely between  the  urethra,  bladder,  and  rectum.  After  cutting 
about  three  inches,  a  flow  of  blood  occurred.  It  was  coagulated 
and  black,  as  blood  would  be  that  had  been  excluded  from  the  air. 
After  the  operation,  a  roll  of  lint  about  the  size  of  the  vagina  was 
introduced,  and  inserted  as  often  as  it  escaped.  This  patient  has 


892  LECTURES    ON    PRACTICAL    SURGERY. 

entirely  recovered,  and  has  a  large  family.  Sometimes  the  hymen  com- 
pletely closes  the  vagina,  and  when  the  passage  becomes  distended 
the  pain  is  excessive,  until  the  hymen  is  divided  either  with  a  lancet 
or  bistoury. 

Occasionally  there  is  an  entire  absence  of  the  vagina  and  uterus, 
and  probably  of  the  ovaries,  although  the  subject  may  be  otherwise 
well  developed.  I  examined,  some  years  ago,  a  lady,  a  stranger  in 
this  city,  who  was  to  all  appearance  physically  perfect.  She  had 
never  menstruated";  the  vagina  was  defective,  the  opening  only  ex- 
tending beyond  the  urethra.  With  another  physician,  a  careful 
examination  was  made,  and  we  decided  that  she  had  neither  vagina 
nor  uterus.  The  lady  was  not  satisfied  when  I  refused  to  perform 
an  operation  for  the  purpose  of  affording  relief,  and  went  to  New 
York,  for  the  purpose  of  consulting  Dr.  Mott.  He  cut  where  the 
vagina  should  have  been,  until  the  peritoneum  was  exposed,  and  then 
very  wisely  declined  to  make  the  incision  deeper.  A  year  elapsed 
before  the  wound  healed.  After  this  unsuccessful  attempt  she  was 
satisfied  that  my  opinion  was  correct.  Even  her  sisters  were  not 
aware  of  the  existence  of  any  difficulty. 

Sometimes  the  -clitoris  is  hypertrophied,  probably  as  the  result  of 
masturbation.  In  such  cases  it  should  be  reduced  to  its  natural  size 
with  either  the  scissors  or  a  scalpel,  or  it  may  be  removed,  as  Erich- 
sen  recommends,  by  either  a  single  or  double  ligature,  and  then  no 
trouble  should  be  apprehended.  Tumors  occasionally  form  in  the 
vagina ;  they  may  be  mucous  polypi,  cystic  tumors,  or  vascular  sar- 
comata. When  of  a  mucous  character,  remove  them  with  the 
scissors  or  forceps;  when  vascular,  apply  a  ligature;  when  they  are 
located  over  the  urethra,  great  care  should  be  taken  not  to  include 
any  portion  of  the  canal.  A  large  gum -elastic  bougie  may  be  in- 
serted, and  in  a  case  upon  which  I  operated  recently,  I  passed  my 
finger  and  thumb  below  the  catheter,  and  Professor  O'Neil  applied 
the  ligature  sufficiently  tight  to  effectually  strangulate  the  tumor. 
In  a  few  hours  a  profuse  discharge  of  blood  took  place  from  the 
uterus,  and  'could  only  be  arrested  by  the  tampon  and  T-bandage. 
The  former  was  removed  on  the  third  day,  the  tumor  came  away  on 
the  sixth,  and  the  patient  left  the  city  on  the  twelfth  day.  The  most 
remarkable  case  of  cystic  tumor  that  I  have  ever  seen  I  operated 
upon  in  1866,  assisted  by  my  nephew,  Dr.  William  Belton,  of 
Colusa  County,,  California,  A  servant  girl,  about  twenty-five  years 


LECTURE    XXXVII.  —  TUMORS    OF    VAGINA.  393 

old,  applied  to  me  for  assistance.  I  found  the  uterus  with  the  entire 
vagina  hanging  between  her  thighs.  The  appearance  of  the  nui- 
cous  membrane  was  entirely  changed,  and  resembled  the  skin  more 
than  the  mucous  membrane.  She  said  that  she  had  been  in  that 
condition  about  seven  years,  and  for  a  long  time  did  not  know,  or 
pretended  that  she  did  not  'know,  that  it  was  anything  either  un- 
natural or  ^dangerous.  The  vagina  and  uterus  could  be  returned, 
but  on  the  rigTit  side  I  could  detect  fluctuation.  I  went  prepared 
to  remove  an  inch  from  each  side,  and  when  the  edges  were  approx- 
imated and  held  in  that  position,  the  vagina  would  be  so  much  con- 
tracted that  the  uterus  could  be  retained  in  its  natural  position  by 
a  pessary  until  it  would  no  longer  have  a  tendency  to  protrude. 
Being  satisfied  by  the  distinct  fluctuation  that  a  cyst  existed,  which 
forced  the  uterus  and  vagina  from  the  pelvis,  I  made  an  incision, 
and  a  pint  of  a  glairy  yellowish  fluid  escaped  ;  the  uterus  was  then 
pressed  upward,  the  walls  of  the  vagina  were  raised  with  common 
forceps,  and  then  the  toothed  spring  forceps  were  applied,  so  as  to 
include  an  inch  in  width  and  three  inches  in  length,  extending  to 
the  inferior  part  of  the  vagina.  Silver  sutures  were  inserted,  and 
the  portion  of  the  vagina  included  in  the  grasp  of  the  forceps  was 
removed  by  strong  curved  scissors.  The  forceps  were  then  applied 
to  the  left  side,  and  the  same  operation  performed.  The  ligatures 
were  removed  in  eight  or  ten  days,  when  the  wounds  had  healed.  A 
stem  pessary  was  introduced,  which  she  had  worn  two  years,  when 
she  came  to  my  office  to  consult  me  in  reference  to  the  propriety  of 
forming  a  matrimonial  alliance.  I  told  her  to  get  married,  and  that 
she  should  wear  the  pessary  during  the  day,  and  if  she  needed  ad- 
vice or  if  she  should  become  pregnant,  I  wanted  her  to  see  me  at 
my  office.  She  married,  but  for  the  last  two  years  I  have  not 
seen  her. 

Sometimes  the  vagina  protrudes  so  as  to  give  considerable  incon- 
venience, and  when  the  patient  becomes  weary  of  the  constant  an- 
noyance, a  double  ligature  should  be  applied  to  the  tumor,  with 
sufficient  force  to  destroy  the  vitality  of  the  part  included,  and  after 
the  ligature  is  detached  the  wound  heals  very  rapidly.  When  a 
prolapsus  of  the  vagina  is  accompanied  with  a  protrusion,  either  of 
the  bladder  or  rectum,  great  care  is  necessary  to  prevent  these  parts 
from  being  included.  Should  the  posterior  portion  of  the  vagina 
protrude,  then  the  finger  should  be  introduced  into  the  rectum,  in 


394  LECTURES    ON    PRACTICAL    SURGERY. 

order  to  ascertain  whether  it  contributes  to  the  enlargement,  and  if 
the  tumor  appears  anteriorly,  the  female  catheter  should  be  used,  so 
that  the  bladder  may  not  be  implicated.  The  vagina  often  becomes 
inflamed,  both  by  specific  and  natural  causes.  The  former  difficulty 
I  have  considered. 

The  leucorrhoeal  discharge  resembles  the  gonorrhceal  so  nearly  that 
it  is  impossible  to  decide  positively  without  an  expensive  examina- 
tion. Generally  I  am  guided  by  the  appearance  of  the  patient  and 
the  circumstances  of  the  case.  Both  children  and  women  of  a  stru- 
mous  diathesis  have  leucorrhcea.  Sometimes  every  female  in  a  family 
is  thus  affected.  Children,  so  soon  as  they  begin  to  get  their  teeth, 
may  have  this  difficulty;  sometimes  it  is  complicated  with  inflam- 
mation of  the  eyes,  discharge  from  the  ears,  and  eczema  of  the  scalp. 
In  such  cases  give  tonics  and  astringent  injections,  and  if  that  local 
treatment  does  not  afford  relief,  introduce  a  glass  pessary,  and  cau- 
terize the  entire  mucous  membrane  of  the  vagina  three  times  a  week; 
by  this  method  I  have  never  failed  to  effect  a  permanent  cure,  when 
combined  with  the  tonic  mixture  which  I  have  already  given,  and  a 
solution  of  sulph.  of  zinc  after  the  character  of  the  disease  has  been 
changed.  I  generally  recommend  from  5iss  to  5\j  of  sulphate  of 
zinc  to  be  put  into  a  quart  of  water,  and  used  with  a  female  syringe 
morning  and  evening,  whilst  in  a  recumbent  position.  It  should  be 
retained  at  least  five  minutes,  and  continued  for  ten  or  fifteen  days 
after  the  discharge  ceases.  This  difficulty  is  almost  always  accom- 
panied with  pains  in  the  back  and  thighs,  with  soreness  across  the 
lower  part  of  the  abdomen.  When  the  mucous  membrane  covering 
the  os  uteri  and  lining  the  entrance  into  the  uterus  becomes  inflamed, 
the  patient  should  be  examined,  and  if  there  remains  attached  to  the 
mouth  of  the  uterus  a  considerable  quantity  of  clear  mucus,  you  will 
almost  always  find  a  diseased  condition  of  the  mucous  membrane 
lining  the  entrance  to  the  uterus.  Always  give  tonics  and  laxatives, 
and  introduce  a  strip  of  lint  half  an  inch  wide,  covered  with  Mon- 
sel's  salt,  as  far  as  the  inner  os,  leave  it  in  that  position  for  two  or 
three  days,  and  if  the  secretion  of  mucus  has  not  been  arrested,  the 
operation  should  be  repeated.  I  formerly  applied  caustic,  but  I  now 
know  there  is  no  comparison  between  these  remedies.  In  cases  of 
menorrhagia  which  have  existed  for  months,  two  applications  are 
generally  sufficient  to  arrest  the  disease.  The  blood  passes  from  the 
inside  of  the  neck  of  the  womb,  and  by  adopting  this  treatment  and 


LECTURE    XXXVII. —  ULCERATIONS    OF    THE    WOMB.       395 

the  ferruginous  preparations  afterwards,  the  patient  will  very  soon 
be  restored  to  perfect  health.  When  a  woman  suffers  from  protracted 
uterine  haemorrhage,  always  make  an  examination  with  the  speculum, 
and  if  no  ulceration  or  polypous  tumor  exists,  introduce  lint  with  the 
precautions  already  given.  Ulcerations  of  the  uterus  are  generally 
accompanied  with  a  purulent  discharge  from  the  vagina,  with  pain 
in  the  back  and  in  the  lower  part  of  the  abdomen,  which  frequently 
extends  to  the  thighs,  and  is  often  the  cause  of  hysteria.  Whenever 
a  female,  if  married,  complains  of  a  choking  sensation,  which  some- 
times continues  constantly,  or  may  recur  at  intervals,  always  examine 
the  uterus  with  a  speculum,  and  if  inflamed  or  ulcerated  cauterize 
the  mucous  membrane  or  the  ulcer  with  nitrate  of  silver  every  alter- 
nate day.  Give  tonics  and  laxatives,  and  very  soon  the  hysterical 
symptoms  will  disappear.  I  returned  from  Europe  in  November, 
1834,  and  very  soon  had  all  the  young  and  old  hysterical  women 
under  my  care.  I  found  by  the  use  of  the  speculum  that  in  every 
case  there  was  either  inflammation  or  ulceration  of  the  mucous  mem- 
brane of  the  os  uteri.  I  treated  them  both  constitutionally  and  locally, 
and  in  ninety-nine  cases  in  a  hundred  they  were  soon  restored  to 
health.  A  few  years  ago  a  woman  came  from  Placerville ;  she  was 
hysterical,  had  dyspepsia,  and  I  told  her  that  I  could  not  give  an 
opinion  without  making  a  speculum  examination.  I  found  the  womb 
ulcerated,  and  told  her  that  travelling  would  not  do  any  good  under 
such  circumstances,  and  that  she  should  return  to  her  Eastern  home. 
I  examined  her  uterus,  and  found  the  os  ulcerated.  I  made  the 
necessary  applications,  and  in  a  few  weeks  the  ulcers  healed,  and  she 
was  restored  to  perfect  health.  In  ulceration  of  the  uterus,  nitrate 
of  silver  should  be  applied  every  alternate  day,  and  such  tonics  and 
laxatives  administered  as  may  be  found  necessary.  I  have  observed 
that  patients  suffering  from  irritation  or  ulceration  of  the  womb  are 
almost  always  constipated,  and  to  obviate  that  and  improve  the 
general  health,  which  is  generally  greatly  impaired,  I  give  my  favor- 
ite tonic,  as  already  directed.  A  simple  excoriation  of  the  neck  of 
the  uterus  may  exist;  in  all  such  cases  apply  the  nitrate  of  silver  a 
few  times,  then  recommend  a  solution  of  Monsel's  salt,  sulphate  of 
zinc,  or  alum,  and  of  course  prescribe  such  constitutional  treatment 
as  the  case  may  require.  In  ulceration  of  the  womb  Velpeau  recom- 
mended the  acid  nitrate  of  mercury  to  be  applied  every  day  for  eight 
or  ten  days,  and  then  discontinued  for  two  weeks.  Should  the  ulcer 


396          LECTURES  ON  PRACTICAL  SURGERY. 

fail  to  heal  then,  the  treatment  should  be  ressmed.  I  prefer  Pro- 
fessor Gross's  method,  which  I  have  already  given.  Sometimes 
females  with  red  hair  and  fair  skin,  which  are  always  accompanied 
with  irritable  mucous  membranes,  suffer  excessively  after  the  appli- 
cation of  the  nitrate  of  silver.  In  such  cases  the  caustic  should  not 
be  reapplied  until  the  pain  subsides  by  means  of  injections  of  tepid 
water  and  the  use  of  narcotics.  After  the  ulcers  heal,  should  the 
neck  of  the  uterus  remain  enlarged  and  indurated,  which  often 
occurs,  I  generally  prescribe  an  alterative  composed  of  iodide  of 
potash  and  corrosive  sublimate  in  proper  doses,  and  puncture  the  os 
uteri  with  a  small  bistoury  or  lancet,  attached  either  to  a  pencil  or  a 
common  redwood  stick ;  numerous  punctures  can  be  made  without 
much  pain,  and  after  being  repeated  several  times,  equal  parts  of 
tinct.  iodine  and  arnica  should  be  applied  with  a  camel's-hair  pencil 
every  alternate  day,  until  the  difficulty  is  removed  or  you  are  satisfied 
that  the  case  is  incurable,  and  then  the  only  hope  that  remains  is 
that  the  difficulty  may  disappear  when  the  age  arrives  for  the  cessa- 
tion of  the  menses.  Displacements  of  the  uterus  are  very  common, 
but  I  am  satisfied  that  they  do  not  produce  the  constitutional  and 
local  symptoms  generally  attributed  to  this  difficulty.  I  am  ac- 
quainted with  four  very  small  women  who  are  suffering  from  pro- 
lapsus of  the  uterus,  and  they  experience  neither  local  nor  constitu- 
tional disturbance.  It  is  very  important  for  you  to  recollect  that 
there  are  between  two  and  three  hundred  pessaries  now  in  use,  and 
the  number  should  be  attributed  to  their  inefficacy.  I  have  never 
used  but  one  pessary  in  my  long  practice  that  gave  me  satisfaction, 
and  that  was  Vane's  stem  pessary.  It  has  been  modified,  but  not 
improved.  I  removed  from  the  vagina  of  an  Irish  girl  a  few 
days  since  a  gum-elastic  pessary,  which  she  had  worn  more  than  ten 
years,  as  the  physician  who  attended  her  died  in  this  city  in  1866. 
The  pessary  when  removed  was  rotten,  and  so  offensive  that  I  was 
compelled  to  destroy  it  before  my  office  hour. 

On  the  inside  of  the  neck  of  the  uterus  yon  will  occasionally  find 
polypoid  tumors.  They  may  be  either  mucous  or  fibrous.  The 
character  is  easily  determined.  The  mucous  polypus  is  transparent, 
always  soft,  and  can  be  removed  with  polypus  forceps  without  the 
slightest  trouble.  After  they  have  been  removed,  lint  wet  and  cov- 
ered with  Monsel's  salt  is  applied  to  the  wound,  and  the  hemor- 
rhage thus  arrested  immediately.  Suppose  you  meet  with  a  fibrous 


LECTURE    XXXVII.  —  CANCER    OF    THE    WOMB.  397 

polypus,  cases  of  which  I  have  often  treated,  a  digital  examination 
is  necessary.  I  think  I  may  say  that  such  tumors  generally  form 
in  the  uterus,  and  when  they  arrive  at  a  certain  size  the  uterus  con- 
tracts, and  the  fibrous  tumor  is  expelled,  and  then  can  be  removed 
with  polypus  forceps  or  the  6craseur  armed  with  iron  wire.  I 
would  advise  you  to  administer  chloroform,  apply  the  forceps  to  the 
tumor,  and  twist  it  off,  and  if  any  difficulty  arises,  the  MonseFs  salt 
can  be  applied  so  as  to  control  the  haemorrhage.  Some  years  since 
a  celebrated  actress  visited  this  city  and  sent  for  me  to  arrest  a 
uterine  haemorrhage,  which  her  physicians  could  not  control.  She 
was  treated  for  prolapsus  of  the  uterus.  By  a  careful  examination  I 
found  the  vagina  filled  with  a  fibrous  tumor.  Dr.  Cameron,  my 
nephew,  assisted  me ;  and  after  the  tumor  was  twisted  off,  lint, 
covered  with  MonsePs  salt,  was  applied,  and  the  patient  recovered 
so  rapidly  that  in  ten  or  fifteen  days  she  left  the  city  perfectly  well. 
Several  more  cases  of  this  character  have  been  trea/ted  by  me  during 
the  last  four  years,,  and  in  some  cases  I  used  the  6craseur  with  a 
strong  iron  wire;  but  in  consequence  of  the  wire  being  liable  to 
break,  I  have  decided  always  to  use  either  the  forceps  or  the  ligature. 
To  determine  the  existence  of  a  cancer,,  the  uterus  should  be  ex- 
amined by  the  touch,  and  its  true  condition  ascertained.  In  the 
treatment  of  cancer  you.  can  palliate,  but  you  cannot  cure  after 
ulceration  takes  place;  give  opium,  hydrate  of  chloral,  and  indeed 
anything  that  will  relieve  pain.  Locally  as  a  disinfectant,.  I  prefer 
the  chlorate  of  potassa;  a  saturated  solution  should  be  used  four  or 
five  times  a  day,  by  which  the  comfort  of  the  patient  may  be  greatly 
increased.  There  are  other  forms  of  malignant  disease  which  do 
not  require  especial  treatment.  I  will  not  detain  you  by  describing 
them,  as  they  were  noticed  particularly  in  my  lectures  on  tumors. 
When  I  was  in  Paris,  Lisfranc  removed  the  uterus.  The  disease 
returned,  and  the  patient  died.  The  uterus  should  not  be  removed 
unless  it  has,  with  at  least  a  portion  of  the  vagina,  presented  exter- 
nally, and  then  if  the  bladder  is  not  implicated,  a  double  ligature 
should  be  applied,  and  the  protruding  part  removed.  Some  years 
since,  Professor  Geddings,  of  Charleston,  published  a.  successful  case 
of  this  character.. 


398          LECTURES  ON  PRACTICAL  SURGERY. 


LECTURE   XXXVIII. 

GENTLEMEN  :  To-day  I  will  say  something  to  you  about  ovarian 
tumors,  a  subject  which  has  very  greatly  increased  in  importance 
within  the  last  twenty  years.  When  I  was  a  student,  much  excite- 
ment was  produced  in  the  entire  community  by  the  first  successful 
operation  for  the  removal  of  an  ovarian  tumor,  which  was  performed 
by  Dr.  McDowell,  of  Kentucky.  He  passed  his  life  in  Kentucky, 
and  did  not  profit,  except  in  reputation,  by  that  great  achievement. 
Great  men  are  often  modest,  and  I  am  certain  that  surrounded  by 
his  friends,  and  secure  in  the  respect  of  his  neighbors,  he  was  much 
happier  than  he  would  have  been  had  he  gone  to  a  large  city. 

Ovarian  tumors  may  be  fibrous,  cysto-sarcornatous,  or  cystic.  The 
latter  are  either  unilocular  or  multilocular.  Unilocular  tumors  con- 
sist of  a  cyst  filled  with  serum.  The  multilocular  are  composed  gen- 
erally of  various  cysts,  and  in  some  cases  no  two  are  filled  with  the 
same  materials.  In  some  of  the  cysts,  in  a  case  upon  which  I  oper- 
ated in  1836, 1  found  a 'fluid  that  resembled  honey;  in  the  adjoining 
cyst  were  found  balls  about  the  size  of  a  marble,  enveloped  with 
hair  ten  or  fifteen  inches  in  length,  and  perfectly  straight.  The 
patient  being  black,  this  seemed  to  be  something  very  extraordinary. 
An  adjoining  cyst  was  filled  with  a  turbid  whitish  fluid,  in  which 
bones  of  various  sizes,  and  irregular  in  shape,  were  lying.  The  con- 
tents of  the  tumor  being  partially  removed,  the  abdomen  was  closed, 
and  the  woman  lived  several  days,  dying  of  peritonitis.  Why  such 
tumors  are  developed,  it  is  impossible  to  ascertain.  An  enlargement 
and  displacement  of  a  kidney,  when  it  extends  down  to  the  pubis, 
may  be  mistaken  for  an  ovarian,  tumor.  I  treated  a  case  of  this 
character  many  years  since.  The  tumor  filled  the  left  side  of  the 
abdominal  cavity,  extending  from  the  ribs  to  the  pubis.  I  made  a 
small  incision,  punctured  the  tumor,  and  not  finding  any  fluid,  I 
examined  the  part  that  presented,  and  was  satisfied  that  what  I  had 
attempted  to  remove  was  a  kidney.  The  wound  was  closed,  and  the 
patient  died  in  ten  or  fifteen  days ;  and  a  post-mortem  being  allowed, 


LECTURE    XXXVIII. — OVARIAN    TUMORS.  399 

the  kidney  was  removed,  and  is  now  in  the  College  Museum.  This 
kidney  weighed  seventeen  pounds  and  a  half.  No  surgeon  should 
be  blamed  for  making  such  a  mistake.  The  pedicle  or  elongated 
attachment  was  nine  inches  in  length,  and  the  inferior  extremity  of 
the  tumor  rested  upon  the  left  side  of  the  pelvis. 

Ovarian  tumors  always  appear  either  on  the  right  or  left  side  of 
the  uterus.  They  give  rise  to  more  or  less  inconvenience,  and  after 
they  have  acquired  considerable  size,  the  position  can  be  easily 
changed,  until  the  distension  becomes  sufficiently  great  to  limit  the 
motion.  When  the  cyst  is  unilocular,  fluctuation  may  be  detected, 
and  may  lead  to  an  error  of  diagnosis,  which  is  always  unpleasant. 
Such  a  mistake  is  often  made.  The  fluctuation  in  unilocular  ovarian 
cysts  is  not  so  distinct  as  in  ascites,  because  the  sac,  as  well  as  the 
abdominal  parietes,  intervenes  between  the  fluid  and  the  hand. 
When  any  doubt  in  reference  to  the  character  of  the  tumor  exists, 
use  an  exploring  needle.  If  fluid  is  found,  perform  the  operation 
for  dropsy,  and  after  the  cavity  has  been  emptied,  you  can  positively 
determine  the  condition  of  the  abdominal  organs.  If  an  ovary  or 
the  ovaries  are  diseased,  then  should  the  effusion  return,  and  the 
patient  desire  permanent  relief,  you  can  select  the  operation  \vhich 
you  prefer,  after  you  have  become  familiar  with  the  methods  recom- 
mended. 

Fibrous  enlargement  of  the  ovaries,  or  the  development  of  fibrous 
tumors  in  them,  may  occasionally  occur.  I  exhibit  one  removed 
by  myself,  which  as  you  see  was  about  as  large  as  a  man's  fist ;  it 
was  movable,  solid,  and  gave  rise  to  some  inconvenience.  The 
woman  came  from  Martinez,  in  this  State,  and  was  determined  to  have 
it  removed.  I  was  assisted  by  Dr.  Russell  and  other  physicians  of 
this  city.  The  tumor  was  removed  through  an  incision  about  four 
inches  in  length,  which  extended  from  the  anterior  spinous  process  of 
the  ilium  downward  and  inward,  and  one  inch  above  Poupart's  liga- 
ment, to  the  inner  extremity  of  the  tumor.  After  exposing  the 
tumor,  the  pedicle  was  secured  by  a  strong  double  ligature,  and  the 
growth  removed.  The  ligatures  were  retained  externally;  strong 
pins  were  passed  through  the  edges  of  the  wound  and  pedicle ;  the 
balance  of  the  former  was  closed  by  the  interrupted  silver  suture, 
and  the  warm-water  dressing  applied,  and  continued  until  the  liga- 
tures were  detached,  and  then  the  edges  of  the  skin  were  approxi- 
mated, except  the  point  occupied  by  a  small  tent,  which  afterwards 


400  LECTURES    ON    PRACTICAL    SURGERY. 

closed  by  granulation.  Very  little  constitutional  disturbance  fol- 
lowed this  operation,  and  she  is  now  well.  She  has  had  three  chil- 
dren since. 

A  cysto-sarcomatous  tumor  is  much  larger  generally  than  a  fibrous. 
I  operated  upon  a  case  of  that  character  three  years  ago ;  Dr.  Lane, 
of  this  city,  was  present.  The  tumor  was  large,  and  the  attachment 
so  extensive  that  the  sae  was  divided,  the  tumor  removed,  and  a 
double  ligature  passed  through  the  base  of  the  sac;  the  remainder 
was  removed.  The  ligature  was  placed  in  the  most  dependent  por- 
tion of  the  incision',  in  order  to  allow  the  secretions  to  escape.  She 
was  very  comfortable  for  two  days;  peritoneal  inflammation  then 
took  place,  and  the  patient  died  from  that  cause  in  four  days  after 
the  operation. 

In  cases  of  unilocular  cystic  tumors,  or  in  other  words,  ovarian 
dropsy,  penetrate  the  tumor,  and  allow  the  canula  to  remain,  in  order 
to  permit  the  fluid  that  may  have  formed  to  escape.  The  canula 
through  which  the  serum  escaped,  being  larger  than  the  one  I  use 
to  drain  the  chest,  I  think  should  be  preferred. 

In  multilocular  tuaiorsr  a  large  incision  must  be  made,  and  the 
tumor  removed ;  the  pedicle  should  be  secured  either  by  a  clamp  or 
strong  ligatures,  and  the  case  treated  subsequently  as  already  de- 
scribed. In  simple  cases  of  ovarian  dropsy,  a  small  incision  should 
be  made ;  the  cyst  should  be  opened  and  the  contents  allowed  to 
escape,  and  then  the  empty  sac  should  be  drawn  out,  secured  by  a 
strong  double  ligature,,  which  should  be  allowed  to  remain  externally 
in  order  to  obtain  drainage.  The  operations  for  ovarian  tumors,  in 
San  Francisco,  have  not  been  successful,  compared  with  reported 
cases.  Dr.  Nelson,  if  living,  is  now  a  resident  of  New  York  city; 
he  operated  upon  two  cases,  and  they  were  both  successful. 

I  have  seen  calculations  made  from  the  result  of  three  hundred 
operations,  in  which  the  tumor  was  removed.  Of  the  three  hun- 
dred, one  hundred  and  oinety  survived,  and  if  that  is  the  average 
result,  the  operation  in  favorable  cases  is  justifiable.  Very  often 
after  making  an  incision,  it  is  impossible  to  remove  the  tumor,  and 
death  is  inevitable,  particularly  when  the  cyst  is  multilocular.  I 
have  operated  in  this  city,  or,  in  other  words,  have  tried  to  operate, 
five  times.  In  one  case  the  tumor  was  not  ovarian,  but  an  enlarged 
kidney,  as  already  mentioned.  In  another  case  a  small  incision 
was  made,  and  fifty-eight  pounds  of  serum  escaped  when  the  open- 


LECTURE    XXXVIII.  —  OVARIAN    TUMORS.  401 

ing  was  enlarged,  so  as  to  enable  me  to  expose  the  ovaries.  I  found 
them  both  extensively  diseased,  and  decided  that  their  removal  was 
impossible,  but  in  both  cases  in  which  I  removed  the  tumor  the  re- 
covery was  complete,  and  in  one  case  the  woman  has  had  several 
children  since. 

I  have  not  operated  upon  ovarian  tumors  as  often  as  might  be 
supposed  from  my  extensive  surgical  practice.  The  reason  is  that  I 
have  never  persuaded  any  person  to  submit  to  a  surgical  operation, 
except  in  cases  of  stone,  aneurism,  and  strangulated  hernia,  diseases 
that  must  prove  fatal  unless  speedily  relieved.  I  never  say  to  a  pa- 
tient, even  if  the  operation  is  slight,  that  no  danger  need  be  appre- 
hended, because  sometimes  death  results  from  the  slightest  injury. 

Ten  years  ago  I  treated  an  unmarried  woman  for  peritonitis. 
She  had  an  ovarian  tumor.  After  she  recovered  I  was  requested  to 
remove  the  tumor,  but  declined,  because  I  knew  that  extensive  ad- 
hesions existed,  and  that  the  operation  would  necessarily  prove  fatal. 
She  then  went  to  St.  Mary's  Hospital.  One  of  the  surgeons  of  that 
institution  removed  the  tumor,  cutting  and  tearing  up  the  adhesions, 
and  she  lived  about  twenty-four  hours  in  the  most  horrible  torment 
which  was  ever  experienced  by  any  human  being.  Her  cries  in- 
terfered with  my  visit.  Had  she  taken  my  advice  she  might  have 
lived  many  years,  and  would  not  have  suffered  so  much  as  she  did 
the  day  she  died.  Out  of  three  hundred  cases  operated  upon,  in  eight 
no  tumor  was  found.  So  that  you  must  be  exceedingly  careful  not 
to  operate  until  you  can  positively  decide  that  an  ovarian  tumor  does 
exist,  and  if  the  patient  desires  its  removal,  you  will  operate.  Rec- 
ollect, in  three  hundred  cases,  in  eight  no  tumor  was  found.  The 
colon  was  probably  impacted,  and  you  should  never  think  of  per- 
forming this  operation  until  you  have  administered  ox-gall  as  a 
purgative,  and  the  infusion  of  senna  leaves  5j  to  the  pint  of  water,  as 
an  enema.  A  few  weeks  since  I  examined  a  lady  who  was  supposed 
to  have  a  tumor  extending  from  the  right  hypogastric  region  to  the 
left  side.  I  ordered  an  enema  of  senna,  one  ounce  to  the  pint  of 
boiling  water.  After  the  intestines  have  been  emptied  by  the  in- 
jection, then  you  should  give  the  antidyspeptic  mixture,  which  I 
then  not  only  described,  but  also  presented  every  student  with  a 
copy.  I  have  been  astonished  by  the  want  of  detail  exhibited  by 
all  the  English  authors.  They  say  to  you,  give  quinine,  give  irou,, 
without  stating  the  object  of  the  prescription.  They  are  almost  al- 

26 


402  LECTURES    ON    PRACTICAL    SURGERY. 

ways  defective  in  detail.  Before  performing  an  operation  of  this 
character,  have  the  bowels  thoroughly  emptied,  as  I  before  stated. 
The  room,  if  the  weather  be  cold,  should  be  heated  artificially  to  the 
temperature  of  75°  or  80°  Fahrenheit,  and  the  condition  of  the  bladder 
should  be  attended  to  especially,  because  when  an  incision  is  made 
from  the  umbilicus  to  the  pelvis,  should  the  bladder  be  distended, 
it  might  be  wounded,  which  would  be  a  very  serious  complication. 
The  patient  should  be  placed  at  the  edge  of  a  table,  the  feet  resting 
upon  two  chairs.  When  the  serum  has  been  removed  from  a  uni- 
locular  cyst,  an  incision  three  or  four  inches  long  should  be  made, 
which  will  be  sufficient  to  enable  you  to  remove  the  sac.  Cases 
may  occur,  however,  when  the  tumor  is  so  large  as  to  require  the 
incision  to  extend  the  entire  length  of  the  linea  alba.  Should  ad- 
hesions exist,  they  may  be  destroyed  by  the  introduction  of  the  hand, 
but  before  the  hand  is  passed  into  the  peritoneal  cavity,  it  should  be 
wet  with  a  fluid  composed  of  the  white  of  an  egg  and  water,  ren- 
dered saline  by  the  addition  of  a  small  quantity  of  common  salt. 
The  hand  being  covered  with  this  artificial  serum,  does  not  produce 
so  much  irritation.  The  incision  is  easily  made,  but  I  am  sorry  to 
say  that  it  is  very  difficult  to  prevent  the  escape  of  the  intestines. 
One  assistant  should  be  placed  upon  each  side  of  the  patient,  with 
his  hands  wet  with  the  solution  already  mentioned,  for  the  purpose 
of  preventing  the  occurrence  of  that  difficulty.  The  serous  mem- 
brane is  irritated  by  coming  in  contact  with  extraneous  matter,  and 
is  liable  to  inflame.  As  the  tumor  is  removed,  the  assistants  should 
press  firmly  on  each  side  so  as  to  approximate  the  edges  of  the 
wound,  and  prevent  the  escape  of  the  contents  of  the  cavity.  When 
the  ligatures  have  been  applied  and  the  sac  or  tumor  removed,  some 
return  both  the  stump  and  the  ligature,  and  close  the  wound  with 
the  silver  suture.  When  that  course  is  pursued  great  success  should 
not  be  expected.  I  am  satisfied  from  my  own  cases,  as  well  as  by  the 
success  of  others  much  more  competent  by  having  had  more  ex- 
perience, that  the  most  successful  method  is  to  draw  the  pedicle 
through  the  wound,  secure  it  by  a  strong  double  ligature,  and  divide 
it  about  half  an  inch  from  the  ligature.  The  incision  should  not  be 
made  too  near  to  the  ligature,  for  if  that  was  not  sufficiently  tight, 
haemorrhage  might  occur,  which  almost  always  proves  fatal.  The 
pedicle  should  be  fastened  to  the  edges  of  the  wound  by  strong 
toilet-pins,  the  wounded  surface  being  external,  and  the  balance  of 


LECTURE    XXXVIII.  —  OVARIOTOMY.  403 

the  wound  should  be  closed  by  the  interrupted  silver  suture.  In 
other  words,  the  pins  should  pass  through  the  pedicle,  and  be  made 
to  include  both  edges  of  the  wound,  and  then  be  secured  by  a  figure- 


FIG.  75. 


of-8  ligature.  For  the  pins  the  clamp  presented  (Fig.  75),  may  be 
substituted,  which  fulfils  the  same  indication.  If  I  were  to  operate  to- 
morrow, I  would  secure  the  pedicle  by  a  strong  double  silk  ligature, 
close  the  wound  firmly  around  it,  and  retain  it  in  that  position. 
Before  the  ligature  is  applied,  you  should  divide  or  remove  the  peri- 
toneum, so  that  it  cannot  be  included  in  the  ligature.  After  the  oper- 
ation the  catheter  should  be  used  in  four  or  five  hours,  or  Sims's 
catheter  should  be  introduced,  with  a  gutta-percha  tube  attached,  a 
yard  in  length,  so  that  the  urine  can  be  conveyed  into  a  receptacle, 
which  will  relieve  the  patient  of  great  annoyance.  The  bowels 
should  not  be  allowed  to  act  for  a  week  or  ten  days.  The  patient 
should  take  corn-meal  gruel,  chicken-water,  beef  tea,  and  indeed 
anything  that  is  simple,  and  that  can  be  almost  entirely  assimilated, 
so  that  very  little  fecal  matter  will  remain.  To  quench  thirst,  give 
a  solution  of  either  gum-arabic  water  or  barley-water,  or  when 
the  stomach  has  not  been  irritable,  lemonade  may  be  allowed,  weak 
and  in  moderate  quantities.  On  the  twelfth  day,  pour  a  pint  of 
boiling  water  upon  one  ounce  of  senna,  cover  it  until  cool,  and  in- 
ject it  into  the  rectum,  by  which  you  will  with  positive  certainty 
cause  the  bowels  to  act.  You  should,  however,  expect  pain  when  the 
indurated  fecal  matter  passes  that  has  been  retained  ten  or  twelve 
days.  The  most  important  part  of  the  treatment  after  all  surgical 
operations  is  to  prevent  pain.  Before  operating  give  a  large  wine- 
glassful  of  good  whisky  or  brandy,  which  always  lessens  the  risk 


404  LECTURES    ON    PRACTICAL    SURGERY. 

of  the  exhibition  of  chloroform,  and  as  soon  as  the  operation  is  com- 
pleted give  a  quarter  of  a  grain  of  sulph.  morph.,  and  repeat  every 
hour  until  relief  is  obtained.  I  can  say  that  I  have  been  very  suc- 
cessful. I  saved  every  patient  from  whom  the  tumor  was  removed. 
There  is  another  difficulty  to  which  I  beg  leave  to  direct  your  at- 
tention before  I  close  this  lecture,  and  that  is,  vesico- vaginal  fistula. 
Thirty  years  ago  this  was  a  very  common  difficulty,  and  generally 
resulted  from  allowing  the  child's  head  to  remain  in  the  passage  too 
long.  I  always  waited  until  after  the  head  ceased  to  advance  four 
hours,  and  then  applied  the  forceps,  and  I  have  never  operated  upon 
the  wife  of  one  of  my  patients  for  a  difficulty  of  this  character,  and 
never  would  if  I  were  to  live  a  hundred  years.  The  first  successful 
operation  was  performed  by  my  friend,  Dr.  Marion  Sims,  a  native 
of  Lancaster  District,  South  Carolina.  He  graduated  and  located  in 
Montgomery,  Alabama,  where  he  performed  the  first  successful 
operation  for  vesico-vaginal  fistula.  The  success  of  that  operation, 
and  bad  health,  caused  him  to  leave  a  Southern  State  and  locate  in 
New  York  city.  When  it  was  ascertained  that  the  operation  was  a 
success,  the  ladies  of  New  York,  headed  by  the  mother  of  one  of 
our  distinguished  citizens,  raised  funds  sufficient  to  build  a  hospital, 
which  is  called  the  Women's  Hospital  of  New  York  City,  and  is 
now  under  the  care  of  Dr.  Emmett,  who  has  never  disgraced  his 
teacher.  Vesico-vaginal  fistula  was  regarded  as  incurable  thirty  or 
thirty-five  years  ago,  and  if  a  Sims  had  not  appeared  in  the  pro- 
fession, it  would  probably  still  have  been  so  considered.  This 
lesion  generally  results  from  tedious  labor.  The  pressure  made  upon 
the  part  that  intervenes  between  the  bones  of  the  head  and  pelvis 
destroys  the  vitality  so  that  it  sloughs,  and  an  opening  is  established 
between  the  bladder  and  vagina.  I  have  delivered  more  than  two 
thousand  women,  and  such  a  thing  never  occurred  in  my  practice, 
because  I  never  allow  a  child,  after  the  progress  of  the  head  has 
been  arrested,  to  remain  in  that  position  more  than  four  hours. 
Then  I  either  use  the  forceps,  or  adopt  other  means.  Should  the 
opening  be  very  small,  you  can  frequently  close  it  with  the  actual 
cautery.  Before  Sims's  discovery  I  cured  two  cases  in  South  Carolina 
by  the  use  of  a  red-hot  knitting  needle,  applied  every  week.  When 
a  cure  cannot  be  effected  in  that  way,  the  only  alternative  that  re- 
mains is  Sims's  operation.  The  patient  should  be  placed  either  upon 
the  side  or  upon  the  knees,  with  four  or  five  pillows  under  the  body 


LECTURE    XXXVIII. — VESICO-VAQINAL    FISTULA.        405 

and  head,  in  order  to  render  her  comfortable.  Then  introduce 
Sims's  duckbill  speculum,  which  exposes  the  part  more  effectually 
than  any  other  instrument.  So  soon  as  the  instrument  is  introduced, 
the  vagina  is  filled  with  air,  and  then  no  difficulty  will  be  experi- 
enced in  keeping  the  parts  in  view.  It  is  useless  to  give  the 
history  of  this  operation,  and  consequently  I  will  only  describe  the 
one  approved  of  and  practiced  by  Sims.  The  edges  of  the  opening 
should  be  freely  removed,  and  the  silver  sutures  inserted  a  fourth  of 
an  inch  apart,  which  may  be  done  either  with  the  small  needle  and 
holder  in  the  Sims  case.  Simpson's  instrument,  which  I  exhibit,  or  one 
which  I  had  made  by  the  Folkers  Brothers,  of  this  city,  when  I 
had  many  operations  of  this  character  to  perform,  is  very  conve- 
nient. If  you  have  experience  you  can  operate  with  anything; 
select  the  instrument  you  prefer,  practice  with  it,  and  you  will  soon 
become  expert.  Dupuytren,  when  in  the  zenith  of  his  glory  at 
Hotel  Dieu,  once  said  to  his  class,  If  you  have  the  head  you  can  al- 
ways find  the  hand.  If  you  cannot  use  your  own  you  can  find  one 
that  will  answer  equally  as  well.  Almost  any  person  can  use  the 
knife  efficiently  when  he  is  not  responsible  for  the  result.  After 
the  edges  of  the  fistulotis  opening  have  been  removed,  and  the  su- 
tures properly  placed,  the  blood  should  be  entirely  removed  and  the 
edges  approximated,  either  by  tying  the  wire  or  twisting  the  edges 
so  as  to  keep  the  surfaces  in  contact  until  the  result  can  be  de- 
termined. Opium  or  sulphate  of  morphia  should  be  administered 
morning  and  evening.  Sims's  catheter  should  be  attached  to  a  tube 
to  conduct  the  urine  from  the  bed.  Gruel,  tea,  chicken-water,  bar- 
ley-water, rice-water,  and  beef  tea,  provided  the  patient  is  debil- 
itated, should  be  prescribed.  The  silver  sutures  should  not  be  re- 
moved for  seven  or  eight  days,  so  that  if  union  by  the  first  intention 
should  not  take  place,  it  might  occur  by  granulation.  The  first  oper- 
ation I  performed  in  this  State,  I  used  the  clamps  made  of  pieces 
of  lead,  perforated  so  as  to  admit  a  silver  wire;  the  edges  were  ap- 
proximated and  the  clamps  held  by  shot  through  which  a  hole  had 
been  made.  When  the  clamps  were  in  a  position  to  hold  the  edges  in 
contact,  the  opening  in  the  shot  was  closed,  and  the  apparatus  was 
not  disturbed  for  ten  days.  The  woman  recovered,  now  lives  in 
this  city,  and  is  perfectly  well. 

i  LIEU  A  K  V 

UNIVERSITY   OF 


406  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   XXXIX. 

GENTLEMEN  :  This  lecture  will  be  devoted  to  diseases  of  the  eye. 
Since  you  have  a  professor  of  ophthalmology,  you  should  not  expect 
from  me  a  minute  description  of  the  anatomy  and  physiology  of  the 
eye.  The  reason  I  did  not  omit  the  diseases  of  this  organ  is,  that 
the  treatment  of  them  is  not  half  so  efficient  and  effectual  as  it  was 
twenty  years  ago.  It  is  true  the  ophthalmoscope  has  been  discovered, 
by  which  you  ascertain  the  condition  of  the  internal  constituents  of 
the  eye  much  better  than  with  ordinary  vision.  When  the  ophthal- 
moscope is  used  the  room  should  be  darkened  and  the  patient  placed 
under  a  gaslight,  his  back  turned  to  the  light,  and  the  instrument 
held  in  front.  The  slightest  opacity  or  organic  disease  can  be  de- 
tected, its  character  generally  ascertained,  and  the  proper  treatment 
adopted,  provided  the  oculist  be  honest. 

The  healthy  eye  is  composed  of  various  parts.  The  membranes 
are  the  conjunctiva,  cornea,  sclerotic,  and  retina.  This  is  the  surgical 
description  of  the  coats  of  the  eye.  Anatomists  frequently  describe 
four  or  five  layers  of  the  cornea,  the  knowledge  of  which  is  of  no 
practical  importance,  and  affords  no  assistance  in  the  treatment  of 
such  cases.  Anteriorly  you  will  find  the  conjunctiva  and  the  cornea. 
They  are  both  transparent;  the  former  covers  the  cornea  and  sclerotic 
membranes,  and  lines  the  lids.  Posterior  to  the  junction  of  the 
cornea  and  sclerotic  there  are  four  membranes,  the  conjunctiva,  the 
sclerotic,  choroid,  and  retina.  Internally  the  eye  is  divided  into  two 
chambers,  the  anterior  and  posterior.  In  the  former  you  will  find 
the  aqueous  humor,  and  in  the  posterior  the  crystalline  lens  and  the 
vitreous  humor.  The  former  is  situated  posterior  to  and  near  the 
iris,  and  the  latter  fills  the  posterior  chamber. 

The  most  common  disease  of  the  eye  in  California  is  acute  inflam- 
mation of  the  conjunctiva.  This  may  result  from  cold,  exposure  to 
strong  light  after  working  many  hours  in  a  dark  tunnel,  or  from  a 
specific  cause.  In  ordinary  cases  of  conjunctivitis  there  is  great 
intolerance  of  light,  but  in  syphilitic  conjunctivitis  the  patient  can 
face  the  strongest  light  without  any  inconvenience.  When  photo- 


LECTURE    XXXIX. — INFLAMMATION    OF    THE    EYE.        407 

phobia  exists,  with  lachrymation,  intense  redness,  and  pain,  the 
disease  must  be  treated  actively  or  the  organ  will  be  destroyed.  You 
should  open  a  vein  in  the  arm,  give  purgatives,  apply  cold  water, 
and  in  twenty-four  hours,  if  decided  relief  has  not  been  obtained,  a 
half  dozen  leeches  should  be  applied  behind  the  ear  of  the  affected 
side,  and  repeated  every  day  so  long  as  the  pain  continues;  then  a 
blister  should  be  applied  behind  the  ears,  and  a  suitable  collyrium 
recommended,  four  drops  of  which  should  be  put  into  the  eye  three 
times  a  day.  Should  leeches  be  scarce,  three  cups,  or  the  abstraction 
of  blood  by  dividing  the  temporal  artery,  should  be  substituted, 
which  will  save  many  eyes,  and  deprive  specialists  of  many  fees, 
both  for  the  operation  and  for  artificial  glass  eyes.  In  syphilitic  con- 
junctivitis the  eyes  may  be  red,  yet  there  is  no  photophobia.  In  such 
cases  apply  to  the  eye  a  few  drops  of  the  solution  of  atropin,  two 
grains  to  the  Sj  of  distilled  water.  You  should  also  give  the  anti- 
syphilitic  mixture  already  recommended  in  other  forms  of  the  same 
disease.  If  not  properly  treated,  in  a  short  time  the  pupil  either 
closes  or  the  member  is  disorganized,  and  consequently  lost. 

Unfortunately  the  diseases  of  the  eye,  both  in  this  and  other  cities 
of  the  United  States,  are  treated  by  quacks,  many  of  whom  do  not 
understand  the  anatomy  of  the  eye,  and  are  entirely  ignorant  of  the 
treatment  necessary  in  every  case.  They  have  a  routine  treatment, 
and  obtain  their  patients  by  runners,  or,  as  they  call  themselves,  so- 
licitors. The  patients  are  both  robbed  and  maltreated,  and  when 
blind  they  must  either  be  treated  gratuitously  or  sent  to  the  hospital, 
where  they  will  receive  proper  attention. 

In  acute  inflammation  of  the  eye,  a  soft  cloth  wet  with  cold  water 
should  hang  loosely  over  the  affected  eye,  and  when  dry  it  should  be 
wet  again,  and  continued.  To  recapitulate,  in  acute  inflammation  of 
the  eye  the  disease  must  be  controlled  by  bleeding  from  the  arm, 
arteriotomy,  leeches,  or  cups,  which  should  be  followed  by  blisters 
and  such  constitutional  treatment  as  the  case  requires.  In  such 
cases  a  few  drops  of  the  solution  of  nitrate  of  silver,  grs.  ij  to  5j  of 
distilled  water,  should  be  applied  to  the  ball  morning  and  evening. 
This  ought  not  to  be  continued  long.  If  it  should  be,  the  conjunc- 
tiva and  cornea  are  permanently  discolored. 

A  very  simple  and  useful  collyrium  contains  the  following  ingre- 
dients :  fy.  Alum,  sulph.,  gr.  xij  ;  vin.  opii,  5ij  ;  aquae  destiL,  §ij. 
Misce.  Sig.  Put  a  few  drops  in  the  eye  three  times  a  day.  Some- 


408  LECTURES    ON    PRACTICAL    SURGERY. 

times  I  prescribe  sulphate  of  zinc,  two  grains  to  the  §j  of  distilled 
water.  One  of  the  best  applications  that  I  know  of  is  the  solution  of 
the  perchloride  of  iron,  twenty  drops  to  the  §j,  although  it  may  be 
made  much  stronger,  and  used  with  a  decidedly  good  effect.  In 
ordinary  cases  of  ophthalmia,  a  few  leeches  behind  the  ear,  fol- 
lowed by  a  blister,  with  cold  applications  to  the  eye,  with  any  of 
the  preparations  above  mentioned,  will  in  a  few  days  relieve  the  in- 
flammation. 

The  most  distressing  disease  of  the  eye  is  called  strumous  ophthal- 
mia. The  eye  is  seldom  red,  but  a  few  enlarged  vessels  may  be 
seen  extending  generally  from  the  corners  of  the  eye,  and  when  they 
reach  the  cornea  a  small  ulcer  generally  appears.  Should  these 
enlarged  vessels  be  touched  with  nitrate  of  silver  near  their  origin, 
they  will  disappear,  the  ulcer  will  heal  rapidly,  and  with  proper 
constitutional  treatment  the  difficulty  will  not  return.  The  question 
now  arises, — what  constitutional  remedies  should  be  recommended? 
Dr.  Mackenzie,  the  distinguished  oculist  of  Edinburgh,  recommends 
sulphate  of  quinia.  He  gave  to  a  child  two  or  three  years  old  two 
grains  three  times  a  day,  and  applied  a  solution  of  nitrate  of  silver, 
grs.  ij  to  the  5],  to  the  eye  morning  and  evening.  I  think  I  have 
improved  Mackenzie's  treatment  by  combining  with  5j  of  sulphate 
of  quinia  Sj  of  the  fluid  ext.  sennse  to  three  ounces  of  simple  syrup. 
This  is  the  best  internal  remedy  that  can  be  given.  When  the  pho- 
tophobia is  distressing,  give  the  internal  treatment.  Use  the  collyr- 
iurn  recommended,  apply  a  blister  behind  the  ear,  and  the  difficulty 
will  soon  be  controlled.  Should  this  disease  attack  adults,  the 
photophobia  is  excessive,  the  patient,  if  a  young  lady,  is  obliged  to 
wear  a  double  green  veil,  the  blinds  must  be  closed,  and  the  curtain 
lowered  so  that  the  least  possible  light  shall  enter  the  apartment. 
You  will  in  such  cases  prescribe — 1^.  Qui.  sulph.,  5j  ;  pul.  rad. 
rhei,  pul.  rad.  sanguinarise  Canad.,  ext.  cicutse,  aa  5ss.  Misce.  Ft. 
pil.  No.  xxx.  Sig.  Take  one  pill  four  times  a  day,  and  use  in  violent 
cases  the  two-grain  solution  of  nitrate  of  silver  locally  to  the  eye. 
In  ordinary  cases  use  the  solutions  of  alum,  zinci  sulph.,  or  any  other 
simple  solution,  and  until  the  photophobia  disappears  the  upper  eyelid 
should  be  inverted  and  touched  with  sulph,  of  copper  every  alternate 
day,  until  the  eye  is  cured.  Some  oculists  in  such  cases  recommend 
cod-liver  oil  internally,  but  I  want  you  to  remember  that  the  effect 
of  cod-liver  oil  is  trifling  in  comparison  to  that  which  results  from 


LECTURE    XXXIX.  —  STRUMOUS    OPHTHALMIA.  409 

the  combination  which  I  have  given.  When  you  graduate,  give  cod- 
liver  oil  to  one  patient  and  the  quinia  mixture  to  another,  and  then 
you  can  decide  correctly.  Many  children  with  this  disease  are 
scrofulous.  Sometimes  this  difficulty  is  complicated  with  eczema  of 
the  scalp,  and  sometimes  of  the  entire  body.  Of  the  latter  trouble  I 
think  I  have  already  spoken;  if  not,  the  professor  of  the  diseases  of 
children  will  lecture  upon  it,  as  it  is  one  of  the  most  common  and 
distressing  diseases  by  which  they  are  afflicted.  Many  years  ago  I 
was  called  to  a  child  fifteen  miles  from  the  little  town  in  which  I 
lived ;  when  I  arrived  the  patient,  a  girl  about  ten  years  old,  who 
had  scrofulous  ophthalmia,  could  not  be  found,  and  finally  the 
mother  dragged  her  from  under  the  bed  with  her  hands  held  to  her 
eyes,  and  screaming  for  fear  that  she  would  be  forced  to  expose  them 
to  the  light.  I  introduced  a  seton  in  the  back  of  the  neck,  gave 
her  sulphate  of  quinia  and  syrup  of  rhubarb,  with  a  two-grain  solu- 
tion of  the  nitrate  of  silver  to  the  Sj  of  water.  In  a  few  weeks  the 
patient  was  well,  and  so  long  as  I  remained  in  Columbia  the  trouble 
did  not  return.  In  all  cases  of  this  character,  prescribe  a  generous 
diet.  Fresh  *neat,  cream,  milk,  and  such  food  as  is  known  to  con- 
tain the  phosphates;  corn-meal,  sweet  potatoes,  beans,  peas,  cracked 
wheat,  and  other  articles  of  diet  of  like  character.  For  the  last  ten 
years  there  has  scarcely  passed  a  day  without  my  seeing  a  case  of 
this  character  in  my  office.  The  child  is  generally  a  blonde,  with 
light  or  red  hair,  and  so  fat  that  you  would  regard  it  as  a  model 
child  if  either  some  one  or  all  of  the  evidences  of  scrofula  did  not 
exist.  Give  quinine  and  the  fluid  extract  of  senna  to  children,  feed 
them  well,  and  under  such  circumstances  I  have  never  failed  to  cure 
a  difficulty  of  this  character.  When  the  disease  attacks  older  chil- 
dren or  adults,  then  give  the  pills  recommended;  evert  the  upper 
eyelid  and  apply  the  sulph.  of  copper  every  alternate  day  until  the 
photophobia  has  entirely  disappeared  and  the  sight  is  restored.  After 
the  application  of  the  nitrate  of  silver  to  the  lids,  a  weak  solution  of 
common  salt  should  be  applied,  which  will  limit  the  action  of  the 
caustic,  and  very  soon  the  disease  will  disappear.  In  cases  of 
strumous  ophthalmia  of  children,  I  sometimes  use  the  solution 
of  alum,  but  nothing  is  so  efficacious  as  the  solution  of  nitrate 
of  silver.  When  used  you  should  always  recollect  that  if  long 
continued  it  renders  the  conjunctiva  and  cornea  permanently  yellow, 
which  may  be  dissected  off  or  removed;  this  may  cause  an  adhesion 


410  LECTURES    ON    PRACTICAL    SURGERY. 

of  the  ball  and  lids,  and  when  the  ball  moves,  the  lids,  being  attached, 
must  perform  the  same  motion.  The  adhesions  between  the  lids  and 
ball  of  the  eye  can  be  divided,  but  considerable  time  and  patience  are 
required  to  remove  the  difficulty  so  as  to  render  the  patient  comfort- 
able, and  that  may  be  accomplished  with  the  knife,  nitrate  of  silver, 
and  common  salt.  A  classmate  of  mine  in  school  was  a  patient  of 
mine;  we  had  read  Virgil  and  Homer  together.  I  always  read  the 
first  half  of  the  lesson,  which  he  did  not  study,  and  he  the  remainder. 
He  recited  half  of  the  lesson  and  I  studied  the  whole.  Being  a 
schoolmate,  I  gave  him  especial  attention.  He  was  poor  and  I  was 
rich,  and  consequently  I  was  more  than  willing  to  give  him  extra 
attention  in  order  to  put  him  in  a  condition  to  support  his  wife  and 
children. 

There  is  another  form  of  inflammation  of  the  eye  which  is  ex- 
ceedingly violent,  and  may  exist  both  in  children  and  adults.  It  is 
called  purulent  ophthalmia.  You  will  meet  with  cases  in  children 
from  two  to  fifteen  or  twenty  days  old.  The  lids  are  swollen  and 
distended  by  the  purulent  secretion,  which  forms  very  rapidly,  and 
should  be  allowed  to  escape  frequently.  This  disease  resembles 
gonorrhoeal  ophthalmia,  and  I  think  generally  results  from  the  eyes 
not  being  properly  washed  with  tepid  water  soon  after  delivery.  I 
think  it  may  be  produced  by  exposing  the  eyes  to  a  strong  light. 
In  such  cases  it  is  very  difficult  to  get  a  view  of  the  ball  of  the  eye, 
and  indeed  I  rarely  attempt  it.  This  disease  is  easily  cured  if  treated 
before  disorganization  takes  place.  You  should  apply  a  four-grain 
solution  of  the  nitrate  of  silver  to  the  ball  and  lids.  Do  not  trust 
either  the  mother  or  nurse  to  apply  the  solution.  A  small  camePs- 
hair  pencil  should  be  selected;  the  hair  should  be  cut  off  with  scis- 
sors close  to  the  quill.  It  should  then  be  dipped  into  the  solution 
of  the  strength  indicated,  and  passed  between  the  lids,  and  brought 
in  contact  with  the  entire  conjunctiva.  This  application  should  be 
repeated  morning  and  evening,  and  the  lids  should  be  separated  at 
least  every  hour,  in  order  to  allow  the  purulent  secretion  to  escape. 
This  treatment  in  my  hands  has  never  failed.  Some  use  a  ten-grain 
solution  of  sulph.  alumina,  other  physicians  apply  a  solution  of 
acetate  of  lead:  to  this  I  decidedly  object  when  the  cornea  is  ulcer- 
ated; the  lead  adheres  to  the  ulcerated  surface,  and  we  do  not  know 
of  any  application  that  will  combine  with  and  remove  it.  I  have 
already  said  that  I  have  never  lost  an  eye  that  was  treated  early, 


LECTURE    XXXIX. — GONORRHCEAL    OPHTHALMIA.          411 

that  is,  soon  after  the  appearance  of  the  disease,  since  I  adopted 
this  treatment,  which  was  published  by  Mackenzie  at  least  thirty 
years  ago,  and  I  do  not  think  that  the  diseases  of  the  eye  are  more 
skilfully  treated  than  they  were  thirty  years  since.  The  treatment 
is  not  so  efficient;  eyes  are  often  lost  when  they  should  be  saved. 
It  is  always  more  profitable  for  a  dishonest  man  to  destroy  an  eye  or 
allow  it  to  become  blind  by  inefficient  treatment,  than  to  prevent  by 
proper  treatment  the  destruction  of  the  organ. 

There  is  another  difficulty  which  occurs  frequently,  but  is  so  de- 
structive that  but  little  time  is  allowed  for  treatment  before  the  eye 
is  disorganized.  It  is  produced  by  gonorrhoeal  matter  coming  in 
contact  with  the  membranes  of  the  eye.  The  conjunctivitis  is  ex- 
cessive, the  membrane  inflames  so  much  and  the  swelling  is  so  great 
that  the  circulation  in  this  membrane  is  interrupted,  and  the  cornea 
sloughs,  which  destroys  permanently  the  function  of  the  organ. 
Sometimes  a  patient  complains  of  a  sore  eye,  and  in  twenty-four 
hours  the  eye  may  be  disorganized.  The  course  which  I  invariably 
pursue  is  that  recommended  by  Sanson,  one  of  the  surgeons  of  the 
Hotel  Dien,  the  best  hospital  in  Paris.  After  the  inflammation  has 
existed  a  few  hours,  apply  a  bandage  to  the  arm,  open  a  vein,  and 
bleed  the  patient  until  syncope  is  threatened.  Then  remove  the 
swollen  mucous  membrane  which  surrounds  the  cornea  and  produces 
the  projection  called  chernosis.  I  always  remove  a  portion  of  the 
entire  membrane,  and  then  the  bleeding  should  be  repeated  if  neces- 
sary; leeches,  cups,  and  blisters  should  be  applied,  and  after  the  re- 
moval of  the  conjunctiva,  solid  nitrate  of  silver  should  be  applied  to 
the  lids,  and  repeated  if  the  circumstances  of  the  case  require  its  ap- 
plication. In  such  cases  I  do  not  bleed  by  the  §j,  but  allow  the  blood 
to  flow  until  syncope  is  threatened.  Should  the  appearance  of  the  eye 
not  improve,  and  the  pain  continue,  venesection  should  be  repeated. 
This  is  the  course  I  have' always  pursued,  and  I  can  say  that  when  I 
was  called  to  a  case  before  disorganization  had  taken  place,  the  eye 
was  always  saved.  Previous  to  Sanson's  day  the  disease  was  consid- 
ered incurable.  I  know  that  it  is  useless  to  try  to  save  an  eye  under 
such  circumstances  by  any  other  method  of  treatment.  In  ordinary 
cases  of  inflammation  of  the  eye,  the  cornea  may  be  ulcerated;  and 
when  the  ulcer  heals,  a  white  spot  remains,  which  is  called  leucoma. 
When  the  ulcer  occurs  over  the  pupil,  this  is  sometimes  a  serious  dif- 
ficulty, and  if  by  the  use  of  the  ordinary  applications,  including  the 


412  LECTURES    ON    PRACTICAL    SURGERY. 

sulphate  of  copper  to  the  lids,  it  is  not  removed,  then  an  artificial  pupil 
can  be  made,  which  may  partially  restore  the  use  of  the  eye,  and  very 
little  deformity  will  remain.  A  nebula  or  cloud  generally  occurs  in 
strumous  cases,  and  results  from  the  enlarged  vessels  of  the  sclerotic 
passing  over  the  cornea,  which  to  some  extent  obscures  the  vision. 
Treat  it  as  a  case  of  strumous  ophthalmia,  with  quinine  and  laxatives 
and  the  local  treatment  already  recommended,  and  you  will  rarely 
fail  to  remove  the  difficulty.  Should  that  course  fail,  then  give 
chloroform ;  have  the  lids  secured,  and  pass  a  point  of  the  nitrate  of 
silver  around  the  ball,  so  as  not  to  touch  the  cornea;  by  this  all  the 
enlarged  vessels  are  destroyed,  and  the  cause  being  removed,  the 
effect  must  speedily  disappear.  After  this  application,  a  weak  solu- 
tion of  common  salt  should  be  employed,  and  morphine  or  McMunn's 
elixir  of  opium  exhibited  until  the  pain  is  relieved.  After  this 
application  you  will  be  astonished  at  the  improvement  that  takes 
place,  if  the  difficulty  has  not  existed  a  long  time.  When  effusion 
occurs  between  the  layers  of  the  cornea  in  consequence  of  the  exist- 
ence of  inflammation  of  that  membrane,  the  lymph  deposited  becomes 
organized,  and  results  in  an  opacity  called  albugo.  It  is  not  a  cica- 
trix,  which  results  from  the  healing  of  an  ulcer,  but  really  an  opacity 
resulting  from  the  effusion  and  organization  of  plastic  lymph  between 
the  layers  of  the  cornea.  An  enlargement  of  the  vessels  is  produced 
generally  by  the  excessive  use  of  the  eyes.  The  vessels  are  very 
conspicuous;  and  when  they  pass  over  the  cornea  until  they  reach 
the  centre,  the  sight  is  impaired.  When  this  difficulty  commences, 
pass  the  nitrate  of  silver  across  the  origin  of  the  vessels,  and  in  nine 
cases  out  often  a  surgical  operation  will  not  be  necessary.  When  it 
does  become  necessary  to  operate,  raise  the  diseased  portion  of  the  con- 
junctiva with  forceps,  dissect  it  off  with  a  scalpel,  and  bring  the  edges 
of  the  wound  together  with  the  interrupted  suture;  they  will  unite 
by  the  first  intention.  After  the  common  operation  a  fungus  gener- 
ally appears  where  the  incision  was  made,  and  the  best  course  is  to 
apply  the  sulphate  of  copper  every  alternate  day  until  the  fungus 
disappears.  Should  that  be  large,  remove  the  tumor,  apply  nitrate 
of  silver  to  the  site,  and  then  use  the  sulphate  of  copper. 


LECTURE    XL. — STAPHYLOMA.  413 


LECTURE  XL. 

GENTLEMEN  :  The  next  disease  of  the  eye  to  which  I  will  direct 
your  attention  is  staphyloma.  The  size  of  the  projection  depends 
upon  the  extent  of  the  ulceration.  When  an  ulcer  forms  upon  the 
cornea,  a  portion  of  the  tunic  is  destroyed,  and  the  remainder 
weakened,  so  that  it  very  soon  yields  to  the  internal  pressure,  and  a 
tumor  is  formed.  When  the  entire  cornea  is  ulcerated,  the  pro- 
trusion is  so  great  that  it  cannot  be  covered  by  the  lids ;  consequently 
the  protrusion  may  be  either  partial  or  general.  When  partial,  it 
results  from  a  small  ulcer,  and  sometimes  the  difficulty  can  be  re- 
lieved by  puncturing  the  projection  with  a  needle,  and  touching  it 
with  nitrate  of  silver,  by  a  repetition  of  which  treatment  the  parts 
are  thickened  by  the  deposition  of  plastic  lymph,  and  become  suffi- 
ciently firm  to  resist  the  pressure  of  the  contents  of  the  eye.  Should 
this  fail,  apply  a  thread  of  silk  to  the  projection,  tie  it  tight,  cut  the 
ligature  close  to  the  knot,  and  you  can  calculate  with  great  certainty 
on  success.  But  when  the  staphyloma  involves  the  entire  cornea, 
you  must  either  remove  the  eye,  or  pass  a  tenaculum  through  the 
tumor,  and  apply  a  strong  ligature,  and  often  you  will  obtain  a 
suitable  stump  for  an  artificial  eye,  which  should  always  be  con- 
sidered. An  artificial  eye  without  motion  is  scarcely  an  improvement. 
The  sclerotic  membrane,  which  is  fibrous,  dense,  and  strong,  some- 
times inflames,  and  the  pain  under  such  circumstances  is  always 
acute.  Being  of  a  rheumatic  character,  it  will  only  yield  to  the  rem- 
edies suitable  in  such  cases.  When  this  difficulty  is  neglected  the 
membrane  becomes  softened,  finally  yields,  and  staphyloma  appears. 
I  have  met  with  and  treated  several  cases  of  this  character,  which 
appeared  under  the  upper  lid  at  first.  I  removed  the  tumor  with  the 
tunics ;  subsequently  iridectomy  was  performed  through  the  sclerotic 
coat,  and  in  every  instance  the  pain  ceased,  and  the  sight  was  not 
lost.  The  patients  were  all  kept  under  the  influence  of  the  following 
mixture  :  3^.  lodid.  pot.,  5iv  ;  vin.  col.  sem.,  syr.  zingiberis,  aa  Siss. ; 
tinct.  aconiti  rad.,  5iss. ;  fluid  ext.  cimicifugae,  Siij.  M.  Sig.  Take 
one  teaspoonful  three  or  four  times  a  day.  This  prescription  in- 


414  LECTURES    ON    PRACTICAL    SURGERY. 

eludes  everything  that  is  useful  in  rheumatism,  no  matter  where  it 
may  be  located,  and  until  the  constitutional  remedy  has  time  to  act, 
the  pain  can  be  relieved  by  the  application  of  leeches  behind  the 
ears,  and  the  use  of  a  grain  of  sulphate  of  morphia  to  a  blistered 
surface  produced  by  the  application  of  ammonia,  as  already  di- 
rected. I  am  opposed  to  the  hypodermic  use  of  morphia  under  all  cir- 
cumstances, not  because  it  does  not  afford  relief,  but  in  consequence 
of  the  means  by  which  it  is  obtained  being  so  convenient  and  at- 
tended with  so  little  pain,  the  temptation  to  repeat  the  operation 
when  the  pain  has  disappeared  is  so  great  that  few  can  resist  it,  and 
ultimately  a  habit  is  formed  which  is  ruinous,  both  physically  and 
mentally.  In  iritis,  which  may  be  either  simple  or  specific,  the 
pain  is  deepseated,  the  pupil  is  generally  contracted,  irregular  in 
shape,  and  grayish  in  color.  In  syphilitic  iritis  you  frequently  find 
these  peculiarities,  and  if  the  disease  is  not  properly  treated,  a  se- 
cretion of  pus  takes  place,  and  the  pupil  closes.  Anti-syphilitic 
remedies  should  be  administered.  Give  calomel  and  opium,  aa.  half 
a  grain  four  times  a  day.  Drop  into  the  eye  a  solution  of  atropin, 
two  grains  to  the  5J,  three  or  four  times  a  day.  Even  in  simple  cases 
of  iritis  give  calomel  and  opium,  use  the  atropin,  and  resort  to 
bloodletting,  as  may  be  indicated  by  the  violence  of  the  disease 
and  the  condition  of  the  patient.  Should  the  pupil  close  and  re- 
main in  that  condition,  lymph  is  secreted,  becomes  organized,  and 
the  occlusion  is  permanent  even  after  the  inflammation  is  controlled. 
The  sight  of  the  eye  can  then  be  easily  restored  by  making  an  arti- 
ficial pupil.  Some  of  the  members  of  the  present  class  witnessed 
an  operation  in  the  hospital  during  the  last  course  of  lectures, 
which  was  successful.  I  found  a  patient  in  the  County  Hospital 
who  had  been  there  over  two  years.  Wilde's  sharp-pointed  scissors 
were  passed  through  the  cornea  at  the  inferior  portion,  the  blades  be- 
ing approximated,  and  an  incision  was  made.  Professor  O'Neil,  who 
was  then  my  student,  caught  the  iris,  drew  it  through  the  opening; 
a  portion  was  removed  and  the  iris  returned.  In  three  or  four 
weeks  the  patient  was  entirely  well,  and  employed  in  the  institution 
as  a  nurse.  Dropsy  of  the  eye  is  not  uncommon.  It  is  produced 
by  an  accumulation  of  fluid  in  the  chambers  of  the  eye,  which  ex- 
pands the  ball,  and  sometimes  destroys  the  sight.  In  consequence 
of  the  dark  color  of  the  secretion,  it  is  called  dropsy  of  the  choroid, 
and  when  the  fluid  accumulates  so  that  the  pressure  produces  an  ab- 


LECTURE    XL.  —  AMAUROSIS.  415 

sorption  of  the  tunics  and  an  irregularity  of  the  enlargement,  the 
dark  color  is  perceptible.  In  such  cases  puncture  the  eye  where 
the  coats  are  thinnest,  with  a  cataract  needle,  so  as  to  allow  the  fluid 
to  escape.  If  a  cure  is  not  thus  effected,  pass  a  tenaculum  through 
the  projecting  point,  and  remove  it  with  a  scalpel,  so  as  to  allow  the 
fluid  to  escape,  and  in  nine  cases  out  of  ten  it  will  not  return,  and 
the  eye  will  perform  its  function  as  well  as  ever.  When  the  secre- 
tion becomes  sufficiently  great  to  produce  pressure,  there  is  much 
pain,  and  an  opening  must  be  made  to  allow  the  fluid  to  escape.  A 
very  common  and  very  serious  disease  of  the  eye  is  called  amaurosis. 
It  is  caused  by  inflammation  of  the  retina.  The  pain  in  such  cases 
in  the  eye  and  head  is  intense,  and  it  maybe  distinguished  from  any 
other  disease  of  the  eye  by  the  fact  that  flashes  of  light  or  sparks 
like  those  from  a  fire  annoy  the  patient,  whether  he  be  asleep  or 
awake.  Whenever  these  symptoms  are  decided,  you  should  feel  sure 
that  you  have  to  contend  with  inflammation  of  the  retina,  which 
requires  the  most  active  treatment  to  remove.  In  such  cases  blood 
should  be  abstracted  either  by  cups  or  leeches,  before  the  patient  is 
paralyzed,  when  the  case  is  generally  hopeless,  because  the  disease 
has  extended  to  the  spinal  cord.  I  have  cured  many  cases  of 
amaurosis,  both  in  my  native  State  and  in  California,  by  the  ab- 
straction of  blood,  at  least  three  times  a  week,  either  from  the 
temples  or  behind  the  ears,  by  cups  or  leeches.  A  case  of  this  char- 
acter cannot  be  cured  except  by  the  abstraction  of  blood,  combined 
with  the  anti-syphilitic  mixture  which  has  already  been  mentioned. 
Formerly  I  employed  a  cupper,  but  as  cupping  is  rather  a  painful 
operation,  I  now  generally  abstract  blood  by  leeches.  They  should 
be  applied  behind  the  ears,  and  by  the  application  of  cloths  wet  with 
warm  water  the  flow  of  blood  should  be  encouraged.  In  addition  to 
the  abstraction  of  blood,  the  bowels  should  be  kept  open,  and  the 
alterative  above  specified  be  administered. 

Have  the  hair  shaved  off  of  three  inches  square  of  the  scalp,  and 
apply  Birt's  blistering  fluid  two  or  three  times  a  week,  or  as  often  as 
may  be  necessary  to  establish  and  keep  up  constant  irritation.  Blis- 
ters to  the  scalp  are  preferable  to  those  behind  the  ears,  because  a 
larger  surface  can  be  attacked,  and  more  irritation  produced  without 
interfering  with  the  abstraction  of  blood.  By  the  treatment  I  have 
recommended  in  the  diseases  specified  I  think  I  can  conscientiously 
say  that  I  have  not  been  mistaken,  and  have  always  prevented  the 


416  LECTURES    ON    PRACTICAL    SURGERY. 

disorganization  of  the  eye,  provided  it  had.  not  occurred  before 
I  was  required  to  treat  the  case.  The  crystalline  lens  I  think  I 
have  not  described,  because  I  expected  to  exhibit  the  lens  of  the  ox. 
It  is  situated  behind  the  iris.  This  membrane  extends  from  the 
junction  of  the  cornea  and  sclerotic  coats,  directly  across  the  eye, 
and  in  the  centre  is  an  opening  which  is  called  the  pupil.  The  an- 
terior chamber  extends  behind  the  pupil  and  is  filled  by  the  aqueous 
humor.  Just  behind,  and  posterior  to  the  anterior  chamber,  we  find 
the  crystalline  lens,  and  behind  it  the  vitreous  humour.  Cataract  is 
an  opacity  of  the  crystalline  lens,  or  of  the  capsule  by  which  it  is 
covered.  In  children  the  cataract  is  white,  which  is  generally 
called  flocculent  or  fleecy,  and  can  be  cured  simply  by  lacerating 
the  capsule  of  the  lens.  Sometimes  the  color  is  gray  or  brownish, 
which  is  generally  the  case  in  adults,  and  particularly  in  old  age. 

The  lens  in  cataract  is  said  to  be  sometimes  black.  I  saw  Jobert? 
at  the  St.  Louis  Hospital,  operate  for  what  he  called  black  cataract 
in  a  case  of  amaurosis.  He  extracted  the  lens,  of  course  without  a 
beneficial  result.  I  recognized  the  patient  as  one  I  had  seen  at  the 
Hotel  Dieu,  and  recollected  that  Dupuytren  said  it  was  amaurosis, 
and  that  an  operation  would  not  restore  the  sight.  The  same  mis- 
take was  made  in  this  city  in  1854,  and  the  patient,  who  was  under 
treatment  in  the  United  States  Marine  Hospital  for  amaurosis,  was 
persuaded  to  leave  that  institution,  which  \vas  then  under  my  con- 
trol. His  eyes  were  operated  upon  for  cataract,  and  he  is  now  a 
living  illustration  of  the  necessity  of  making  a  correct  diagnosis  in 
such  cases,  and  will  serve  as  a  caution  to  those  who  are  always  ready 
and  willing  to  operate  upon  anything  regardless  of  consequences, 
provided  they  can  obtain  notoriety.  A  singular  case  occurred  in  my 
practice  recently.  I  operated  upon  a  woman  for  soft  cataract  by 
laceration  of  the  capsule.  In  a  few  weeks  the  cataract  disappeared, 
and  her  sight,  with  the  assistance  of  a  glass  with  a  three-inch  focus, 
was  as  good  as  before  the  lens  became  diseased.  In  a  few  months, 
however,  I  ascertained  that  she  had  capsular  cataract,  which  I  think 
was  produced  by  the  constant  use  of  the  eye,  which  should  have 
been  favored.  Two  weeks  since  I  removed  the  capsule  through  the 
cornea,  and  now  the  sight  is  as  good  as  after  the  first  operation. 
In  persons  more  advanced  the  lens  presents  a  brownish  appearance, 
and  sometimes  resembles  amaurosis  or  iritis,  when  pus  is  secreted  by 
the  inflamed  vessels.  When  in  doubt,  use  the  atropin,  2  grs.  to 


LECTURE  XL.  —  TREATMENT  OF  CATARACT.      417 

the  Sj  of  distilled  water,  three  or  four  times  a  day,  and  the  following 
morning,  by  the  use  of  the  ophthalmoscope,  a  correct  diagnosis  can 
be  made.  In  amaurosis  a  gray  appearance  is  presented,  in  cataract 
either  a  white  or  brownish  substance  intervenes  between  the  pupil 
and  the  vitreous  humor.  The  causes  of  cataract  are  not  easily 
ascertained,  except  in  such  cases  as  are  produced  by  violence.  After 
the  receipt  of  an  injury,  several  months  may  elapse  before  the  dis- 
covery is  made  that  one  eye  is  defective.  An  oculist  is  at  length  con- 
sulted; he  finds  a  cataract  in  the  eye  that  sustained  the  injury,  and 
extracts  the  lens.  The  eye  is  now  blind,  and  the  difficulty  cannot 
be  removed  by  any  subsequent  operation.  I  recollect  a  blacksmith 
who  was  injured  by  a  piece  of  iron  striking  his  eye;  a  cataract 
formed.  I  watched  the  case,  and  in  three  or  four  months  the 
cataract  was  extracted,  and  the  eye  was  apparently  perfectly  well, 
but  in  order  to  render  the  sight  equal  in  both  eyes,  a  glass  with  a 
three-inch  focus  should  cover  the  injured  eye,  and  a  plain  glass 
should  be  used  for  the  other.  You  should  never  operate  upon  a 
cataract  of  one  eye  when  the  other  is  not  affected.  I  once  operated 
upon  one  eye,  the  sight  of  the  other  not  being  very  good.  The  pa- 
tient was  a  colored  servant ;  with  both  eyes  exposed  he  could  not  cut 
a  stick  of  wood.  He  was  obliged  to  cover  the  eye  upon  which  the 
operation  was  performed,  and  to  keep  it  covered  until  the  sight  of 
the  other  eye  was  so  much  improved  that  he  could  perform  the  du- 
ties required  of  a  servant.  I  then  depressed  the  cataract  of  the  other 
eye,  and  in  two  weeks  the  sight  was  not  only  restored,  but  no  in- 
convenience was  experienced. 

You  should  never  operate  for  cataract  by  an  injury  if  the  other 
eye  is  perfect,  lest  both  eyes  be  destroyed.  If  saved,  the  focus  being 
different,  but  little  benefit  will  result  from  the  operation,  and  the 
other  and  healthy  eye  may  be  involved  and  the  sight  destroyed.  A 
case  of  this  character  occurred  in  my  native  State.  One  eye  was  in- 
jured by  the  accidental  explosion  of  powder ;  Dr.  Wells  operated 
upon  the  affected  eye,  the  other  eye  became  implicated,  and  was  saved 
only  by  venesection,  leeches,  cups,  blisters,  and  evaporating  lotions. 

Should  no  inflammation  follow  the  operation,  in  one  eye  you  will 
find  a  lens,  and  in  the  other  none.  The  sight  is  so  much  confused 
that  the  condition  of  the  patient  is  more  uncomfortable  than  before, 
and  he  is  either  compelled  to  cover  one  of  the  eyes  or  have  the  lens 
removed  from  the  other  eye,  in  order  to  render  both  eyes  useful  at 

27 


418          LECTURES  ON  PRACTICAL  SURGERY. 

the  same  time.  The  question  now  arises,  how  a  cataract  can  be 
cured  in  young  persons  when  it  is  flocculent,  or  in  children  when 
the  sight  is  defective  in  consequence  of  a  laminated  condition  of  the 
lens,  which  is  only  partially  transparent?  I  have  always  succeeded 
by  laceration.  When  the  capsule  is  lacerated,  the  lens  is  dissolved 
by  the  aqueous  humor.  In  hard  cataract,  the  lens  dissolves  very 
slowly  when  lacerated,  and  consequently  I  have  always  performed 
the  operation  practiced  by  Dupuytren,  at  the  Hotel  Dieu.  In  soft 
cataract  the  lens  was  lacerated,  and  not  otherwise  disturbed,  and 
when  the  cataract  was  hard,  it  was  removed  from  the  axis  of  vision 
and  allowed  to  remain.  I  watched  the  result  and  compared  it  with 
the  result  of  Professor  Roux's  operations.  He  performed  the  flap, 
and  always  extracted.  The  incision  was  made  upon  the  external 
and  lower  side  of  the  cornea ;  the  capsule  of  the  lens  was  divided 
with  a  small  knife,  and  the  lens  removed  from  its  natural  position 
and  forced  through  both  the  pupil  and  wound. 

Roux  was  so  popular  as  an  operator  that  I  saw  him  perform  the 
operation  for  cataract  by  extraction  on  twenty-eight  eyes  before  he 
left  his  seat.  Dupuytren,  during  the  month,  generally  operated 
upon  five  or  six  every  morning  by  candlelight.  I  watched  closely 
every  case  that  was  operated  upon  in  both  La  Charite  and  Hotel 
Dieu,  and  I  had  abundant  evidence  that  laceration  and  couching 
were  more  successful  than  extraction,  as  then  practiced,  by  the  flap 
operation.  I  noticed  that  the  wound  of  the  cornea  failed  to  unite  by 
the  first  intention;  sometimes  iritis  followed  the  operation,  and  not 
being  treated  actively,  the  sight  was  lost.  I  adopted  Dupuytren's 
treatment  in  such  cases,  and  if  I  live  to  lecture  ten  years  longer,  I 
will  advise  every  class  to  pursue  the  course  which  has  been  so  suc- 
cessful in  my  hands. 

When  you  desire  simply  to  lacerate  the  lens,  pass  a  cataract-needle 
either  above  or  below  the  centre  of  the  external  surface  of  the  eye- 
ball (if  curved,  turn  the  convex  side  to  the  iris).  When  the  needle 
can  be  seen  through  the  pupil  which  has  been  dilated,  then  change 
the  position,  and  if  the  cataract  is  soft,  lacerate  it,  and  if  hard,  pass 
the  needle  over  the  lens  and  press  it  down  into  the  posterior  cham- 
ber, or  in  other  words,  into  the  vitreous  humor,  where  I  have 
never  known  it  to  produce  either  inflammation,  irritation,  or  paraly- 
sis. I  was  the  only  surgeon  in  the  interior  of  South  Carolina  who  did 
operate  upon  the  eyes,  and  who  had  independence  enough  to  use  the 


LECTURE    XL.  —  OPERATIONS    FOR     CATARACT.  419 

lancet,  and  I  can  say  that  I  never  lost  but  one  eye  after  an  operation 
for  cataract,  and  this  patient  positively  refused  to  submit  to  vene- 
section or  the  abstraction  of  blood  by  other  means  when  inflamma- 
tion occurred.  When  the  lens  is  depressed,  the  light  can  pass  into 
the  posterior  chamber  of  the  eye  through  the  pupil.  After  the 
operation  for  cataract,  the  sight  is  not  so  good,  but  by  the  use  of 
glasses  the  patient  can  read  ordinary  print,  and  the  sight  is  suffi- 
ciently restored  for  the  transaction  of  any  business.  The  operation 
by  extraction  is  now  almost  universally  practiced,  and  for  that  pur- 
pose the  best  instrument  I  have  ever  used  is  Wilde's  iridectomy 
scissors.  With  them  you  can  make  as  extensive  an  incision  as 
may  be  necessary,  with  less  difficulty  than  with  any  other  instru- 
ment. 

The  operation  for  cataract  by  linear  extraction  only  differs  from 
any  other  in  that  the  incision  is  made  in  the  upper  portion  of  the 
cornea  instead  of  in  the  lower.  In  skilful  hands,  I  have  no  doubt 
this  has  its  advantages.  After  the  incision  of  the  cornea  has  been 
made,  then  the  capsule  should  be  divided,  and  by  gentle  pressure, 
the  lens  should  be  removed.  I  have  occasionally  performed  this 
operation,  and  generally — unless  the  pupil  has  been  closed  either  by 
a  wound  or  by  inflammation — the  sight  has  been  restored  ;  if  not,  the 
operation  of  iridectomy  may  be  necessary  to  restore  vision.  In  soft 
cataract,  it  is  immaterial  what  operation  may  be  recommended, 
always  lacerate.  When  the  lens  is  soft,  operate  through  the  cornea. 
Dilate  the  pupil  with  two  grs.  of  atropin  to  §ij  of  water,  and  then 
pass  the  needle  through  the  cornea  and  lacerate  the  capsule.  That 
operation  is  called  keratonyxis,  and  when  the  needle  is  passed  through 
the  sclerotic  coat,  it  is  called  sclerotonyxis.  In  all  cases,  before 
operating  for  cataract,  the  pupil  should  be  dilated  by  atropin. 

For  holding  the  lids  apart,  the  instrument  exhibited  is  very  effi- 
cient, and  I  do  not  think  it  can  be  improved ;  time  would  only  be 
lost  in  the  search  for  other  inventions.  Sometimes  the  eye  becomes 
cancerous,  and  should  be  removed  according  to  the  size  of  the  sur- 
rounding parts  that  are  implicated.  Raise  and  divide  the  con- 
junctiva, which  will  allow  the  finger  to  pass  between  the  eye  and 
the  orbit,  so  as  to  break  up  any  adhesions  that  may  exist,  and  enable 
you  to  apply  a  ligature  to  the  vessels  and  nerves  sufficiently  tight  to* 
destroy  the  sensibility  of  the  nerves  and  control  the  artery  so  effectu- 
ally as  to  prevent  hemorrhage.  When  entropium  exists,  the  eye  can- 


420  LECTURES    ON    PRACTICAL    SURGERY. 

not  be  entirely  opened  ;  the  eyeball  is  either  inflamed  or  the  cornea 
opaque  from  the  irritation  produced  by  the  lashes  rubbing  constantly 
upon  the  ball.  When  entropium  is  complicated  with  an  inversion 
of  the  lashes,  the  difficulty  is  called  trichiasis.  Entropium  is  not 
uncommon,  and  is  almost  always  produced  by  neglected  strumous 
ophthalmia.  The  only  operation  that  can  be  performed  successfully 
is  to  remove  a  sufficient  portion  of  the  eyelids  with  the  subcutaneous 
cellular  tissue,  and  confine  the  surfaces  of  the  wound  in  contact,  and 
allow  the  ligatures  to  remain  until  union  is  perfect;  a  second  opera- 
tion is  seldom  required.  Should  the  difficulty  return,  the  operation 
may  be  repeated  with  success. 

Ectropium  is  regarded  as  a  much  more  unmanageable  difficulty, 
but  I  must  confess  that  I  would  much  rather  treat  a  case  of  this 
character  than  one  of  entropium.  In  ectropium,  the  inside  of  the 
lid  is  turned  outward,  the  mucous  membrane  is  exposed  and  presents 
a  peculiar  red  appearance,  wrhich  is  always  very  unpleasant ;  the  eye 
suffers  from  light  and  dust,  and  often  becomes  inflamed.  When  I 
came  to  California,  in  1852,  I  had  never  operated  upon  a  case  of 
this  character.  Very  soon  the  wife  of  a  clergyman,  who  had  ectro- 
pium of  both  lids,  applied  to  me  for  relief.  By  the  assistance  of  one 
of  my  best  students,  the  lower  eyelid  was  dissected  out  without 
injuring  the  cartilage.  A  portion  of  skin  large  enough  to  fill  the 
wound  was  taken  from  the  temple,  turned  upon  its  pedicle,  placed  in 
the  opening,  and  secured  by  interrupted  silver  sutures.  These 
should  be  allowed  to  remain  six,  seven,  eight,  or  ten  days,  and  then 
be  removed.  The  upper  lid  was  more  everted  and  disfigured  than 
the  lower.  When  the  first  operation  was  successful,  I  dissected 
the  cartilage  and  mucous  membrane  from  the  parts  to  which  it  was 
attached.  A  piece  of  skin  was  taken  from  the  temporal  region, 
which  was  placed  in  the  position  required  to  remove  the  deformity, 
and  held  there  by  sutures. 

In  such  cases  a  failure  cannot  occur.  Some  years  since,  a  girl  was 
brought  to  this  city  with  ectropium  of  an  aggravated  character, 
produced  by  the  horn  of  a  vicious  cow.  The  under  lid  was  everted. 
I  told  the  mother  that  it  was  necessary  to  dissect  up  the  lid,  take  a 
piece  of  skin  large  enough  to  hold  the  lid  in  its  natural  position,  re- 
tain it  in  that  position  until  union  occurred,  and  then  she  would  be 
well.  She  decided  that  she  would  not  submit  to  any  such  barbarity. 
She  employed  an  oculist  and  a  surgeon.  They  performed  seven 


LECTURE    XL.  —  FISTULA    LACHRYMALIS.  421 

operations,  and  after  each  operation  the  difficulty  increased.  She 
finally  paid  their  bill  and  employed  me.  I  transplanted  a  piece  of 
skin,  and  the  deformity  was  removed,  but  I  am  sorry  to  say  that  she 
did  not  express  any  gratitude  for  the  attention  which  I  rendered. 
Cases  of  ectropium  are  sometimes  due  to  the  action  of  fire,  or  the  rays 
of  the  sun.  The  face  is  blistered,  and  when  the  blisters  heal,  the 
cicatrix  contracts,  and  the  eyelids  are  everted.  You  should  always 
stop  and  tell  the  mother  to  grease  the  face  with  mutton-suet  after 
it  is  washed,  but  not  with  soap.  Soap  should  never  be  applied 
to  the  human  skin,  and  oil  (either  mutton  suet,  almond  oil,  or 
olive  oil)  should  be  applied  every  day,  as  oil  protects  the  human 
skin. 

Encanthus  is  a  tumor  near  the  inner  corner  of  the  eye;  some- 
times it  is  quite  large ;  it  is  vascular,  and  occasionally  presents  a 
granulated  appearance.  The  only  treatment  necessary  is  to  apply 
a  ligature.  You  will  find  by  experience  that  the  ligature  is  the 
most  successful  method  of  treatment.  When  it  is  detached,  there 
is  scarcely  a  possibility  of  return  of  the  tumor  unless  it  be  malig- 
nant. 

Epithelioma. — If  you  recollect,  I  described  this  as  a  semi-malig- 
nant tumor,  which,  when  neglected  or  irritated,  may  return.  To 
distinguish  it  from  cancer,  it  is  called  sometimes  cancroid.  In 
epithelioma  of  the  eyelids,  you  must  remove  the  parts  implicated, 
and  supply  the  defect  from  the  adjoining  healthy  tissue.  In  the 
cases  represented  in  Figs.  42  and  43  (pp.  134-5)  a  portion  of 
the  upper  and  under  eyelids  were  removed,  and  very  little  de- 
formity resulted.  The  man  had  not  as  much  control  over  the  lids 
as  he  had  formerly,  but  his  sight  was  not  impaired. 

Fistula  lachrymalis  generally  results  from  the  obstruction  of  the 
lachrymal  ducts  and  the  carelessness  of  the  patient.  When  the 
duct  closes,  the  tears  accumulate  in  the  sac,  and  if  that  is  not 
emptied  by  pressure  several  times  a  day,  it  inflames,  pus  is  formed,, 
the  skin  ulcerates  from  distension,  and  a  fistula  lachrymalis  is  the 
result.  This  can  be  cured  by  passing  a  round-headed  probe  through 
the  puncture.  I  do  not  use  AnePs,  but  one  which  I  had  made  by 
Glaze  and  Radcliffe,  of  Columbia,  South  Carolina,  and  with  it  I 
cured  a  patient  after  Delafield  and  a  celebrated  oculist  of  New 
Orleans  had  failed.  Before  I  left  the  State,  Mrs.  Preston,  the 
patient,  could  pass  the  probe  as  readily  as  I  could,  and  she  was- 


422          LECTURES  ON  PRACTICAL  SURGERY. 

permanently  cured.  When  your  patients  are  not  wealthy,  and  live 
at  a  distance  from  you,  you  should  have  a  tube  like  Dupuytren's, 
made  of  pure  gold;  cut  an  opening  into  the  lachrymal  sac,  pass  a 
curved  director  through  the  duct  into  the  nasal  cavity,  which  should 
be  followed  by  the  gold  tube  exhibited.  The  external  wound  will 
heal  readily,  and  the  head  of  the  tube  being  concealed,  no  deformity 
will  or  can  result.  I  am  now  treating  a  patient  from  Chico,  who 
has  dyspepsia,  and,  having  seen  her  before,  I  asked  her  if  she  had 
not  been  my  patient.  She  said  that  her  eyes,  when  a  girl,  were  very 
weak,  and  when  she  came  to  San  Francisco  her  relations  sent  her  to 
me,  and  that  I  inserted  a  gold  tube,  which  has  remained  fifteen  years 
without  producing  the  slightest  inconvenience,  and  the  only  evidence 
that  an  operation  was  performed  is  that  a  yellow  and  rough  spot 
remains.  Formerly  a  seton  was  passed  from  the  fistulous  opening 
to  the  nose.  Subsequently  a  stilette  of  gutta  percha,  with  a  head,  was 
passed  through  the  duct  and  allowed  to  remain  until  the  canal  was 
permanently  re-established.  After  the  stilette  is  withdrawn,  the 
stricture  frequently  reappears ;  but  if  the  Dupuytren  tube,  made  of 
pure  gold,  is  inserted,  the  wound  heals  over  the  tube,  and  the  patient 
is  permanently  relieved. 

When  you  desire  to  steady  the  eye,  always  use  the  blunt  forceps ; 
they  take  hold  of  the  conjunctiva  and  control  the  movements  of  the 
eye  without  causing  much  pain.  A  delicate  instrument  would  slip 
and  the  operation  be  delayed,  until  the  broad  forceps  were  used, 
which  are  found  in  every  properly  prepared  case,  entirely  sufficient 
to  control  the  movements  of  the  eye  under  any  circumstances. 

I  was  the  first  surgeon  in  America  who  performed  the  operation 
for  strabismus,  and  I  now  allude  to  the  fact  in  order  to  encourage 
the  members  of  this  class  to  take  the  journals,  so  as  to  keep  them- 
selves familiar  with  the  literature  of  the  profession.  I  then  read  the 
quarterly,  published  in  Philadelphia,  called  the  American  Medical 
Journal.  I  also  read  the  Medico- Chirurgical  Review,  published  in 
London.  I  also  took  and  read  a  local  journal,  and  contributed  very 
liberally  to  its  columns. 

WThen  the  eye  occupies  an  unnatural  position,  the  deformity  de- 
pends upon  either  a  congenital  shortening  of  the  muscles  or  upon  a 
contraction  of  the  rectus  muscles.  I  have  already  described  the  dif- 
ferent varieties  of  this  deformity,  and  it  is  not  necessary  now  to 
repeat  what  was  then  said.  The  lids  being  secured,  have  the  eye- 


LECTURE  XL. — OPERATION  FOR  STRABISMUS      423 

ball  steadied  by  an  assistant  with  blunt  forceps ;  then  raise  the  con- 
junctiva with  small  forceps,  snip  a  small  portion,  or  divide  the  part 
elevated  with  a  tenotomy  knife;  pass  a  small  curved  director 
under  the  tendon  of  the  muscle,  and  divide  it  by  passing  the  blade 
along  the  groove  until  the  resistance  ceases.  When  the  muscle  is 
very  much  shortened,  I  generally  pass  a  small  pair  of  curved  scis- 
sors under  the  director,  so  as  to  remove  a  portion  of  the  tendon  raised 
up,  which  will  enable  the  eye  to  resume  at  once  its  natural  position. 
This  operation  is  generally  simple,  although  many  fail,  after  the 
tendon  has  been  properly  divided,  for  want  of  experience.  Should 
the  eye  be  disposed  to  turn  too  much  in  a  contrary  direction,  then 
the  eye  should  be  covered  and  the  other  exposed,  until  they  both 
present  the  same  appearance,  and  they  should  be  exposed  to  the  light, 
being  simply  protected  by  a  shade.  Should  the  eye  operated  upon 
have  a  disposition  to  retain  its  original  position,  then  it  should  be 
exposed  and  the  other  covered  until  it  presents  a  natural  appearance, 
and  when  that  occurs,  expose  both.  In  females,  the  eye  is  greatly 
disposed  to  turn  in  the  opposite  direction ;  hence  the  tendon  should 
only  be  divided  and  the  eye  covered  until  it  unites,  provided  there 
is  a  tendency  to  eversion  of  the  .ball.  Gentlemen,  I  have  always 
read  the  journals,  and  about  1840, 1  read  in  the  Medico- Chirurgical 
Review,  that  Dieffenbach  had  performed  that  operation  successfully 
for  strabismus,  and  before  my  competitors  were  aware  of  the  fact,  I 
had  operated  upon  at  least  half  a  dozen  cases,  which  gave  me  all  the 
ophthalmic  surgery  in  my  native  State,  as  well  as  in  the  upper  part 
of  the  two  adjoining  States. 

When  a  fungus  appears  where  the  incision  was  made,  apply  the 
sulphate  of  copper  every  alternate  day  until  it  disappears. 


424  LECTURES    ON    PRACTICAL    SURGERY. 


LECTURE   XLI. 

GENTLEMEN  :  There  is  another  subject  of  very  great  importance 
to  which  I  have  not  alluded.  It  is  important  to  medical  men,  and 
particularly  to  young  practitioners,  and  that  is  spermatorrhoea.  You 
will  find,  when  you  engage  in  practice,  that  almost  every  person  who 
has  practiced  masturbation  thinks  he  has  spermatorrhoea.  This 
impression  is  made  by  reading  the  tracts  distributed  by  charlatans, 
both  in  this  and  in  other  States.  It  is  a  misfortune  that  this  is  true, 
although  I  have  no  doubt  that  it  has  rescued  many  valuable  men 
from  ruin,  who  would  not  have  been  aware  of  the  consequence  of 
excessive  indulgence  until  they  were  destroyed,  both  physically  arid 
mentally.  These  publications,  however,  are  calculated  to  injure  the 
illiterate,  since,  after  reading  productions  of  this  character,  they  be- 
lieve that  the  slightest  escape  of  semen  must  soon  prove  fatal,  and 
they  will  give  their  last  dollar  to  any  man  who  calls  himself  a  phy- 
sician. They  think  constantly  of  the  dreadful  fate  that  awaits  them, 
and  ultimately  the  health  becomes  impaired,  and  very  soon  they 
are  found  in  the  lunatic  asylum,  or  I  should  say  asylums,  for  the 
asylum  at  Napa  is  being  rapidly  filled ;  the  other  at  Stockton  con- 
tains more  than  a  thousand  lunatics,  and  many  have  resulted  from 
this  cause.  The  loss  of  semen  is  natural ;  it  is  necessary ;  and  it 
only  becomes  a  disease  when  excessive.  After  an  erection  either 
prostatic  fluid  or  semen  will  escape.  That  is  the  natural  consequence 
of  an  erection  in  young  persons ;  it  is,  therefore,  not  disease.  A  man 
of  intelligence  can  be  made  to  understand  this,  but  illiterate  and 
otherwise  ordinary  men  cannot  be  convinced  by  reason,  and  these  are 
the  most  troublesome  cases  that  you  will  ever  be  required  to  treat. 
They  only  apply  to  the  best  regular  physicians  after  they  have  been 
robbed  of  their  money.  In  many  cases  they  have  paid  every  cent 
they  possessed  to  an  uncompromising  and  dishonest  quack.  These 
publications  have  been  pecuniarily  very  beneficial  to  me,  because  the 
patients  of  the  better  class  soon  detect  humbug.  Such  patients  pay 
liberally,  because  no  regular  physician  charges  more  than  the  legal 


LECTURE    XLI.  —  SPERM ATORRHCE A.  425 

fee,  and  they  have  been  charged  so  exorbitantly  by  a  man  who  is 
entirely  ignorant  of  the  first  principles  of  medicine.  I  once  appeared 
as  an  examiner  with  Dr.  Henry  Gibbons,  of  a  notorious  quack  of 
this  city,  who  had  sued  another  quack  for  libel.  The  charlatan  did 
not  know  where  the  liver  was  located.  He  failed  to  answer  a  single 
question,  and  then  withdrew  the  suit,  sold  his  diploma,  and  retired. 
You  should  say  to  every  patient  that  it  is  impossible  to  prevent  noc- 
turnal emissions  entirely ;  but  when  they  occur  so  often  as  to  produce 
both  local  and  general  debility,  by  proper  treatment  the  recurrence 
can  be  reduced  to  once  a  week,  and  even  sometimes  to  once  a  month. 
The  most  frequent  cause  is  masturbation.  Excessive  indulgence 
is  another  fruitful  source  of  the  disease.  It  frequently  follows 
gonorrhoea,  and  results  from  the  irritation  of  the  prostatic  portion  of 
the  urethra  which  remains  after  the  discharge. 

Causes. — It  sometimes  accompanies  stricture,  varicocele,  or  any 
irritation  either  of  the  prostatic  portion  of  the  urethra  or  of  the  neck 
of  the  bladder.  The  irritation  of  the  parts  specified  causes  an 
increased  secretion  of  semen,  which  must  escape,  and  which  will 
escape  more  frequently  than  if  the  parts  were  in  a  healthy  condition. 
Sometimes  the  semen  passes  when  at  stool,  very  frequently  at  night 
during  dreams,  which  at  first  afford  pleasure,  but  ultimately  the 
fluid  passes  with  only  a  partial  erection,  and  without  the  slightest 
pleasure.  In  this  state  the  condition  of  the  patient  is  very  unhappy. 
The  seminal  fluid  changes  its  character,  becoming  thinner  and  more 
abundant;  ultimately  the  body  smells  like  semen.  The  digestive 
organs  in  some  cases  are  deranged ;  there  is  troublesome  flatulence, 
with  constipation;  palpitation  of  the  heart  generally  exists;  the 
nights  are  sleepless,  and  the  patient  becomes  stupid  and  cowardly. 
The  unfortunate  victim  is  almost  always  impotent;  although  it  is 
impossible  to  have  an  erection,  the  least  excitement  causes  a  dis- 
charge of  semen.  The  first  officer  of  the  ship  in  which  I  crossed  the 
Atlantic  became  paralyzed  from  this  habit ;  and  when  he  was  un- 
able to  use  the  hands,  having  some  control  over  his  arms,  he  managed 
to  produce  the  desired  effect  in  that  manner.  This  man  died  in  the 
Marine  Hospital  at  Havre  a  few  days  after  the  ship  landed.  It  is 
perfectly  astonishing  that  men  of  ordinary  intelligence  will  indulge 
any  passion  to  the  extent  to  which  it  is  often  practiced.  I  saw  in  La 
Charite  Hospital,  in  Paris,  a  young  man,  who  had  disease  of  the 
spine.  He  was  emaciated  and  miserable,  and  acknowledged  that  he 


426  LECTURES    ON    PRACTICAL    SURGERY. 

had  masturbated  three  times  a  'day  for  more  than  seven  years. 
Boyer  thought  that  the  disease  of  the  spine  was  produced  by  that 
cause.  Another  case  is  described  in  Richerand's  Physiology  of  a  shep- 
herd, I  think  a  Swiss,  who  had  masturbated  until  he  could  not  pro- 
duce an  emission  by  friction,  and  had  actually  split  the  penis,  so  as  to 
find  a  portion  of  the  urethra  on  which,  by  using  a  straw,  the  desired 
eifect  could  be  produced.  So  soon  as  the  part  exposed  by  the  opera- 
tion lost  its  sensibility,  the  cutting  was  repeated  until  the  urethra 
was  divided  below  the  scrotum,  and  on  one  occasion  he  unfortunately 
passed  a  foreign  body  into  the  bladder,  and  was  admitted  into  the 
hospital  to  be  treated  for  stone.  Sometimes,  in  cases  of  spermator- 
rhoea,  the  general  health  remains  good,  but  sooner  or  later  the  patient 
becomes  impotent.  Of  course  a  case  of  this  character  requires  dif- 
ferent treatment,  which  will  be  specified  when  that  form  of  the  dis- 
ease is  under  consideration. 

You  should  be  careful  not  to  mistake  a  discharge  of  mucus  for 
semen.  I  can  generally  distinguish  between  them  by  the  fact  that 
semen  adheres  to  the  fingers  when  touched;  but  if  doubt  exists,  the 
fluid  should  be  examined  with  the  microscope,  when  its  character 
can  be  easily  determined.  Many  years  ago  a  celebrated  French 
physician  supposed  he  had  discovered  an  infallible  remedy  for 
spermatorrhoea ;  he  wrote  two  octavo  volumes  on  the  treatment  of 
this  disease  by  the  use  of  nitrate  of  silver  combined  with  constitu- 
tional remedies.  His  success,  I  am  satisfied,  depended  more  on  the 
constitutional  than  local  treatment.  I  have  used  the  porte-caustique 
times  innumerable,  over  a  month,  as  recommended  by  Lallemand, 
every  two  weeks,  every  week,  and  sometimes  every  two  or  three 
days,  and  I  can  conscientiously  say  that  I  have  never  in  my  life 
obtained,  by  the  use  of  that  instrument,  the  slightest  benefit.  I 
have  not,  unless  requested  by  a  patient,  used  the  porte-caustique  for 
fifteen  years,  and  I  do  not  think  I  ever  will  use  it  again  unless  it 
may  be  necessary  to  cauterize  a  local  irritation  of  the  urethra.  About 
fifteen  years  ago,  an  old  physician  of  San  Francisco,  who  did  not 
practice,  asked  me  if  I  had  ever  used  the  extract  of  belladonna  for  the 
purpose  of  invigorating  the  urinary  organs;  he  said  that  he,  although 
over  sixty  years  of  age,  after  taking  it  for  two  or  three  weeks,  found 
that  the  venereal  propensity  returned  with  more  vigor  than  had  ex- 
isted for  ten  years.  Being  aware  that  the  extract  of  mix  vomica 
was  the  best  tonic  known  to  the  profession  generally,  and  that  it 


LECTURE    XLI.  —  SPERM  ATORRHCE  A.  427 

acted  specifically  upon  the  genital  organs,  I  made  this  combination  : 
R.  Quinise  sulph.,  5j  ;  pulv.  rad.  rhei  and  ext.  nucis  vom.,  5ss. ;  ext. 
bellad.,  gr.  xij.  M.  Ft  pil.  No.  xxx.  Sig.  Take  one  pill  four 
times  a  day.  Should  the  patient  be  large,  you  can  recommend  four 
pills  a  day.  In  cases  accompanied  with  daily  emissions,  with 
debility,  constipation,  and  indigestion,  if  the  pills  recommended  do 
not  produce  the  desired  effect,  you  can  give  the  following  combina- 
tion:  II.  Ext.  senna?,  5iij;  tinct.  nucis  vomicse,  5ix;  tinct.  bellad., 
5iiss.;  tinct.  aconiti  rad.,  acid,  hydrocyanici,  aa  5iss.  M.  Sig. 
Take  one  teaspoonful  four  times  a  day. 

Such  patients  should  be  fed  well,  the  bowels  should  act  every  day, 
and  they  should  abstain  from  the  popular  dish  in  this  city  composed 
of  corned  beef  and  cabbage.  The  latter  often  attains  the  weight  of 
forty-five  pounds,  and  is  not  digestible;  it  is  only  preferred  by 
laboring  men  in  consequence  of  its  lasting  qualities.  In  cases  in 
which  there  is  excessive  irritability,  with  good  general  health,  I 
would,  under  all  circumstances,  prescribe  the  following  mixture:  1^. 
Potass,  bromidi,  §v;  ext.  senna?  fl.,  §iij;  tinct.  belladonna?,  5iiss.; 
tinct.  aconiti  rad.,  acid,  hydrocyanici,  aa  5iss. ;  syr.  simplicis,  Siiss. 
M.  Sig.  Take  one  teaspoonful  four  times  a  day.  The  patient  should 
live  temperately,  take  active  exercise,  and  in  a  short  time,  great  im- 
provement will  be  perceptible,  and  particularly  when  the  dyspeptic 
symptoms  are  prominent.  I  am  satisfied  that  nearly  one-half  of  the 
cases  of  insanity  in  the  lunatic  asylums  have  resulted  from  mastur- 
bation. They  very  soon  lose  all  sense  of  decency.  Yesterday 
morning,  at  the  County  Hospital  gate,  I  saw  a  man  masturbating. 
He  was  a  thin,  pale,  emaciated  wretch,  and  has  undoubtedly  brought 
himself  to  that  degraded  condition  by  masturbation.  At  the  alms- 
house  in  this  city,  I  have  ascertained  that  there  are  fifteen  or  twenty 
wretches  who  are  not  demented,  but  who  masturbate  without  regard 
to  those  present.  This  is  in  one  of  the  best-managed  institutions  in 
the  world. 

I  think  that  the  legislature  should  pass  a  law  to  punish  every 
man  or  woman  who  cannot  resist  masturbation  ;  the  former  should 
be  castrated,  and  the  latter  subjected  to  removal  of  the  clitoris  and 
nymphse,  and  the  application  of  croton  oil;  should  that  fail,  then  they 
should  have  their  hands  tied  and  be  watched  constantly  until  the 
habit  is  destroyed. 

There  is,  as  I  before  stated,  another  difficulty  which  results  from 


428  LECTURES    ON    PRACTICAL    SURGERY. 

this  habit,  and  that  is  impotence.  I  have  already  directed  you  how 
to  treat  a  condition  of  this  character.  When  the  general  health  is 
good,  give  the  bromide  of  potash,  bellad.,  senna,  aconite,  etc.  Impo- 
tence, when  the  patient  is  healthy,  results  from  two  causes.  First, 
want  of  confidence.  When  a  man  visits  a  woman  under  suspicious 
circumstances,  and  fails  from  the  fear  of  detection,  he  should  never 
renew  the  effort  unless  the  night  can  be  spent  with  her,  and  all 
dread  of  exposure  is  removed.  Impotence  may  result  from  excess, 
but  I  think  the  most  common  cause  is  masturbation.  When  there 
exists  in  young  girls  incontinence  of  urine,  I  am  generally  suspicious 
that  it  has  resulted  from  masturbation.  This  difficulty  should  be 
attended  to  promptly  and  efficiently,  as  previously  recommended. 


LECTURE    XLII.  —  SKIN    GRAFTING.  429 


LECTURE   XLII. 

SKIN-GRAFTING. 

M.  L.  REVERDIN  discovered,  in  1869,  that  skin  taken  from  a 
different  part  of  the  body  and  applied  to  an  ulcerated  surface,  would 
adhere  and  hasten  the  cicatrization  of  the  ulcer.  He  grafted  the 
epidermis  with  as  small  a  portion  of  the  cutis  vera  as  possible. 
They  sometimes  failed  in  consequence  of  the  bloodvessels,  by  which 
the  granulations  are  supplied,  not  extending  into  the  true  skin,  which 
supports  the  epidermis  and  furnishes  the  material  by  which  cicatriza- 
tion is  accomplished.  Oilier,  in  1872,  applied  large  portions  of  the 
skin,  which  should  receive  the  name  of  "  cutaneous  transplanta- 
tion." He  claims  that  the  cicatrix  is  like  the  true  skin,  and  does 
not  contract,  and  consequently  is  not  followed  by  the  serious  and 
often  fatal  consequences  of  an  extensive  cicatrix  resulting  from  a 
burn.  From  the  date  of  Dr.  Ollier's  case,  it  is  apparent  that  the 
credit  of  the  operation  he  performed  belonged  to  California,  as  will 
be  substantiated  by  the  following  case: 

E.  Ragauisse,  aged  forty-two  years,  a  native  of  France,  and  a 
laundryman  by  occupation,  was  admitted  into  the  County  Hospital, 
September  9th,  1871,  with  both  legs  scalded  from  the  knees  to  the 
ankles.  It  was  a  burn  of  the  second  degree ;  when  the  skin  sloughed 
two  large,  deep,  and  painful  ulcers  was  the  result.  At  the  expira- 
tion of  six  weeks  they  had  not  perceptibly  diminished,  and  the  pa- 
tient having  consented  to  the  operation,  it  was  performed  in  the 
presence  of  the  class  of  the  Medical  College.  A  portion  of  the 
skin  of  the  right  arm,  three  inches  long  and  half  an  inch  wide, 
was  removed.  The  true  skin  was  dissected  off  carefully,  so  as  to 
remove  the  subcutaneous  cellular  tissue,  which,  after  being  washed 
in  tepid  water,  was  divided  into  six  equal  parts ;  they  were  applied 
three  on  each  leg,  as  represented  by  Fig.  76,  and  secured  by  the 
application  of  adhesive  plaster.  The  ulcer  was  dressed  daily  with 
simple  cerate,  and  on  the  seventh  day  the  plasters  were  removed ; 


430 


LECTURES    ON    PRACTICAL    SURGERY. 


the  only  change  that  was  observed  in  the  grafted  portions  of  the 
skin  was  that  the  cuticle  seemed  to  be  detached,  and  they  were  a 
shade  lighter  in  color  and  smoother  than  when  placed  in  contact 
with  the  ulcerated  surface. 

Fig.  77  represents  the  appearance  of  the  ulcers  three  weeks  after 


FIG.  76. 


FIG.  77. 


the  operation,  and  in  four  months  both  of  the  ulcers  were  entirely 
healed,  and  he  left  the  County  Hospital. 

This  method  was  adopted  in  consequence  of  the  result  of  the 
operation  of  Reverdin,  in  this  city,  being  so  unsatisfactory,  although 
I  \vas  not  aware  that  it  was  the  first  that  had  ever  been  performed 
of  the  same  character. 

This  patient  was  examined  whilst  in  the  County  Hospital  by  the 
physicians  and  surgeons  of  the  county,  by  the  members  of  the  class, 
as  well  as  by  Professor  Morse,  and  many  of  the  other  physicians  of 
San  Francisco. 


LECTURE    XLII.  —  EPITHELIOMA. 


431 


EPITHELIOMA. 

Mary  Murry,  when  placed  under  my  treatment,  was  suffering 
from  an  epitheloma  of  the  lower  eyelid.  After  remaining  at  St. 
Mary's  Hospital  for  several  weeks  without  obtaining  relief,  she  ap- 
plied to  a  cancer  doctor  of  this  city,  who  applied  escharotics  so 
powerful  that  the  periosteum  of  the  malar  bone  was  destroyed,  and 
the  bone  became  carious.  There  being  but  one  course  of  treatment 


FIG.  78. 


indicated,  assisted  by  my  nephew,  Dr.  W.  H.  Bel  ton,  of  Colusa,  in 
July,  1865,  at  the  corner  of  Green  and  Sansom  Streets,  I  removed 
the  lower  lid,  chiselled  off  the  diseased  bone,  and  by  transplanting 
a  sufficiently  large  portion  of  the  skin  from  the  side  of  the  forehead 
supplied  the  defect.  The  skin  transplanted  adhered,  the  deformity 
was  removed,  and  she  now  enjoys  good  health,  is  married,  and  living 
in  this  city. 


432  LECTURES    ON    PRACTICAL    SURGERY. 


DEFOKMITIES   OF   THE   NOSE. 

Deformities  of  the  nose  which  result  either  from  fractures  of  the 
nasal  bones  or  laceration  and  displacement  of  the  cartilage  which 
forms  the  septum,  change  the  expression  of  the  face  more  than  any 
other  injury,  and  when  accompanied  with  much  swelling,  may  not 
be  detected  until  after  the  fracture  has  united  or  the  cartilage  has 
formed  other  attachments  which  produce  deformities  that  have  here- 
tofore been  considered  incurable.  Fig.  79  represents  a  case  of  this 
character  occurring  in  my  practice  some  time  since. 

Miss  P.,  while  endeavoring  to  light  the  gas,  fell  from  a  chair  upon 
her  face,  in  consequence  of  being  exhausted  from  loss  of  sleep  during 
the  protracted  illness  of  her  mother.  Twelve  or  fifteen  hours 
elapsed  before  I  examined  the  injured  part,  and  then  it  was  enor- 
mously swollen.  The  nasal  bones  were  not  injured,  but  it  was  not 
possible  to  determine  what  other  injury  had  been  sustained.  Two 
or  three  days  after  the  occurrence,  I  lost  sight  of  the  case  in  conse- 
quence of  the  death  of  the  mother  and  a  change  of  residence.  After 
living  two  years  in  New  York  she  returned  to  San  Franciso,  about 
four  months  since,  greatly  disfigured  on  account  of  the  nose  being 
flattened,  and  the  apex  turned  to  the  right  side.  She  visited  this 
city  with  the  hope  of  having  an  operation  performed  that  would  re- 
move the  deformity,  and  in  consequence  of  the  great  anxiety  ex- 
hibited, I  consented,  being  confident  that  the  deformity  would  not 
be  increased. 

After  having  had  the  instrument  represented  in  the  cut  made  by 
Messrs.  Folkers  &  Co.,  the  cartilage  was  detached  from  the  inner 
side  of  the  nasal  bones  by  a  subcutaneous  section  with  an  ordinary 
tenotomy  knife,  the  incision  being  made  inward  and  slightly  down- 
ward. A  steel-pointed  harelip  pin  was  then  passed  from  above  the 
incision  through  the  portion  that  had  been  depressed  obliquely,  and 
escaped  about  an  inch  below  the  incision.  Others  were  inserted  in 
the  centre  of  the  nose — one  a  few  lines  above  the  other — and  passed 
out  on  the  side  as  previously  stated,  about  half  an  inch  from  the  ex- 
tremity of  the  organ.  The  apparatus  was  then  applied  to  assist  the 
pins  to  overcome  the  lateral  curvature.  The  pins  were  removed  the 
tenth  day,  but  finding  that  the  newly  formed  attachment  was  not 


LECTURE    XLII.  —  DEFORMITIES    OF    THE    NOSE. 


433 


sufficiently  fir.m  and  extensive,  another  pin  was  passed  from  the 
centre  of  the  nose  through  the  cartilage  and  below  the  incision  about 
half  an  inch,  and  brought  out  near  the  centre,  but  slightly  to  the 


FIG.  79. 


right.     This  was  allowed 
was  produced,  and  when 
the  part  indicated  that  a 
deposited,  and  organized, 
rence   of  the  difficulty, 
wounds  produced  by  the 
only  a  very  slight  cicatrix. 
several  months. 


to  remain  until  considerable  inflammation 

removed,  the  appearance  and  firmness  of 
considerable  quantity  of  lymph  had  been 

I  think,  sufficiently  to  prevent  the  recur- 
No  deformity  is  now  perceptible;  the 

insertion  of  the  pins  have  healed,  leaving 
She  will  wear  the  apparatus  at  night  for 


BUNIONS. 


A  bunion  is  generally  produced  by  pressure,  and  the  swelling  is 
caused  by  inflammation  of  the  tissues  which  cover  the  metatarso- 
phalangeal  joint  of  the  great  toe.  The  bursa  in  some  cases  be- 

28 


434 


LECTURES    ON    PRACTICAL    SURGERY. 


FIG.  80. 


comes   diseased,  and   a   subcutaneous   incision    with   sorbefacients, 
as  recommended  by  Prof.  Gross,  often  gives  relief.     Occasionally 

the  bone  enlarges  so  much  as  to  dis- 
figure the  foot  greatly,  without  being 
very  painful,  but  generally  the  pain  is 
very  great,  and  the  ordinary  remedies  fail 
to  afford  relief.  For  such  cases,  what 
should  be  done?  The  unfortunate  man 
or  woman  must  either  be  allowed  to  suffer 
from  the  consequences  of  the  folly  of  wear- 
ing small  shoes,  or  submit  to  an  operation 
by  which  they  can  obtain  permanent  re- 
lief. 

Excision  of  the  head  of  the  first  meta- 
tarsal  bone  for  the  cure  of  bunion,  is  il- 
lustrated by  three  successful  cases  : 

CASE  I. — A.  G.,  a  German,  about  35 
years  of  age,  entered  the  hospital  in  July, 
1875,  to  receive  treatment  for  ulcerated 
bunions  of  the  metatarso-phalangeal  articulations  of  both  feet. 

The  great  toe  of  each  foot  was  turned  outward,  and  overlapped  the 
second  and  third  toes.  The  articular  surface  of  the  first  phalanx 
was  displaced  inward,  producing  a  remarkable  prominence  at  the 
extremity  of  the  metatarsal  bone.  The  pain  in  walking  was  so 
severe  as  to  render  locomotion  almost  impossible. 

The  ulcers  soon  healed  under  the  influence  of  rest  and  a  dressing 
of  simple  cerate.  Efforts  were  repeatedly  made  to  bring  the  toes 
into  their  proper  places  by  mechanical  means,  but  without  success. 
It  was  finally  determined  to  remove  the  enlarged  inner  part  of  the 
head  of  the  metatarsal  bone,  which  was  done  in  the  following 
manner: 

A  straight  incision  an  inch  and  a  half  in  length  was  made  along 
the  inner  border  of  the  metatarsal  bone,  extending  from  the  anterior 
extremity  over  the  prominence  of  the  bunion  to  a  point  about  an 
inch  anterior  to  the  posterior  extremity  of  the  bone.  The  tissues 
were  then  dissected  from  the  bony  projection,  care  being  taken  not 
to  open  the  articulation.  The  prominence  was  then  removed  with 


LECTURE    XLII.  —  BUNIONS. 


435 


the  saw,  in  a  line  parallel  with  the  axis  of  the  bone.  The  sharp 
edges  of  the  bone  were  bevelled  off  with  the  chisel,  and  the  edges  of 
the  incision  were  brought  together  and  united  with  several  silver 
sutures.  A  dressing  of  simple  cerate  was  then  applied.  The  toe 
was  now  easily  brought  into  its  natural  position,  and  was  kept  in 
place  by  means  of  a  straight  splint,  extending  along  the  inner  margin 
of  the  foot,  from  the  heel  to  the  extremity  of  the  great  toe.  It  was 
well  padded  with  cotton,  and  secured  to  the  foot  by  a  bandage,  the 
toe  being  thus  firmly  retained  in  its  proper  position. 


FIG. 81 . 


Cured  bunion. 


Both  feet  were  operated  upon  at  the  same  time  in  this  manner. 
The  wounds  healed  promptly,  after  which  passive  movement  of  the 
articulation  was  kept  up  in  order  to  prevent  anchylosis.  The  splints 
were  removed  after  the  third  week,  when  it  was  found  that  the  de- 
formity was  entirely  relieved,  the  toe  being  on  a  line  with  the  inner 
margin  of  the  foot.  The  appearance  and  function  of  the  feet  were 
in  every  way  as  perfect  as  could  have  been  desired.  Over  a  year 


436  LECTURES    ON    PRACTICAL    SURGERY. 

has  passed  since  the  operation,  and  his  feet  have  given  him  no  trouble 
whatever. 

CASE  II. — A  book  agent,  F.  F.,  aged  46  years,  entered  the  hos- 
pital in  May,  1876,  with  an  ulcerated  bunion  of  the  left  foot,  of 
several  months7  standing.  The  great  toe  was  displaced  inward,  and 
overlapped  the  second  and  third  toes,  as  in  Case  I.  The  metatarso- 
phalangeal  articulation  was  much  swollen,  and  the  slightest  pressure 
gave  great  pain.  The  ulcer  was  about  six  lines  in  diameter,  and 
occupied  the  prominence  of  the  bunion.  In  a  short  time  the  ulcer 
healed,  leaving  a  hard  tender  projection  in  its  stead. 

As  the  patient  had  previously  been  subjected  to  a  variety  of  me- 
chanical appliances  without  benefit,  the  case  seemed  a  suitable  one 
for  partial  excision.  In  this  instance  an  oval  incision  was  made 
through  the  skin  on  the  inner  surface  of  the  metatarsal  bone,  so  as 
to  include  the  indurated  tissues  over  the  bunion.  The  head  of  the 
bone  was  found  to  be  enlarged  and  also  diseased,  the  cancellous  tissue 
being  much  softened.  The  entire  head  of  the  bone  was  removed  by 
carrying  the  knife  through  the  articulation,  severing  the  lateral  liga- 
ments, and  dividing  the  bone  with  the  chain-saw  just  posterior  to 
the  head.  The  edges  of  the  incision  were  brought  together  anteriorly. 
Posteriorly  an  opening  was  left  for  drainage,  as  that  end  of  the 
wound,  being  dependent,  afforded  the  most  ready  outlet  to  the  dis- 
charge. The  toe  was  brought  into  proper  position,  and  retained  by 
a  splint  as  in  Case  I.  Slight  suppuration  followed,  but  by  the  sixth 
week  the  wound  had  healed,  and  the  motion  of  the  toe  was  perfect. 
A  new  joint  had  evidently  been  formed.  The  foot  differed  from  its 
fellow  only  in  being  a  few  lines  shorter.  In  two  months  after  the 
operation,  F.  F.  resumed  his  occupation  of  canvassing,  and  has  since 
been  free  from  pain  or  inconvenience. 

CASE  III. — Mrs.  B.,  a  lady  of  47  years  of  age,  a  book  canvasser, 
and  accustomed  to  walking  several  hours  every  day,  entered  the  hos- 
pital in  September,  1876,  with  an  ulcerated  bunion  of  the  left  foot, 
which  had  of  late  become  so  painful  as  to  prevent  her  from  pursuing 
her  occupation.  She  had  suffered  from  the  difficulty  for  many  years, 
and  had  received  every  variety  of  treatment  without  benefit.  In 
this  case  excision  of  the  head  of  the  bone  was  performed  as  in  Case 


LECTURE   XLII.  —  BUNIONS.  437 

II,  but  without  waiting  until  the  ulcer  had  healed.  The  diseased 
tissues  were  included  in  an  elliptical  incision,  as  in  the  foregoing 
case. 

The  result  was  all  that  could  have  been  desired.  No  appreciable 
deformity  exists,  and  she  now  walks  with  more  comfort  than  for 
years  before.  She  is  now  on  her  way  to  the  East,  and  expresses 
great  dissatisfaction  with  the  result  of  the  treatment  heretofore  re- 
ceived. 


RY 


CALIFORNIA^ 


SYPHILIS  AND  ITS  TREATMENT, 


LECTUKE    XLIII. 

GENTLEMEN  :  Formerly  lues  venerea  and  morbus  venereus  were 
the  terms  employed  to  designate  the  local  affections  resulting  from 
impure  sexual  intercourse.  The  word  pox  was  applied  to  the  va- 
rious affections  of  the  skin,  which  appear  after  it  has  become  consti- 
tutional, from  their  resemblance  to  the  pustules  which  characterize 
small-pox. 

Syphilis  is  the  term  now  universally  employed  to  distinguish 
every  variety  of  this  insidious,  disgusting,  and  formidable  disease. 
For  this  we  are  indebted  to  Fracastor,  who  has  represented  in  his 
poem,  that  a  shepherd  called  Syphilus  was  the  first  who  suffered 
from,  and  presented  all  the  symptoms  of  this  affection,  being  a  pun- 
ishment inflicted  upon  him  by  an  offended  deity.  Whether  true  or 
false,  the  name  has  been  retained,  and  is  as  convenient  as  any  other 
that  could  be  employed. 

Much  difference  of  opinion  exists  respecting  the  origin  of  the  dis- 
ease and  the  date  of  its  appearance.  Many  believe  that  it  is  coeval 
with  the  human  family,  and  base  their  opinion  upon  the  unques- 
tionable existence  of  the  affections  of  the  genital  organs  many  centu- 
ries before  the  discovery  of  America.  Hippocrates  was  familiar  with 
ulcers  and  cutaneous  affections  which  are  now  attributed  to  the  in- 
fluence of  that  poison.  Celstis  described  many  that  are  at  present 
regarded  as  venereal,  and  from  his  description  both  simple  and  indu- 
rated chancres  might  be  readily  recognized,  although  he  was  not 
ignorant  of  the  existence  of  phi mosis  and  paraphimosis ;  to  use  the 
language  of  Vidal,  he  neither  wrote  a  work  upon  the  subject,  gave 
them  a  name,  nor  indicated  a  specific  treatment. 


440  LECTURES    ON    PRACTICAL    SURGERY. 

Notwithstanding  these  affections  were  accurately  described  by  the 
ancients,  they  were  regarded  as  the  results  of  simple  inflammation  in 
consequence  of  their  ignorance  of  a  specific  cause,  and  the  relation 
that  existed  between  it  and  the  symptoms. 

To  William  of  Salicet  we  are  indebted  for  a  description  of  a  swell- 
ing in  the  groin,  resulting  from  ulcers  on  the  prepuce,  and  Lan- 
franc  mentions  the  same  difficulty  produced  by  ulcerations  of  the 
penis.  "Scepe  provenat  apostema  in  inguine  propter  ulcer e  virgce, 
propterea  quod  est  descensus  humorum  ad  ilia  /oca."  This  language 
cannot  receive  any  other  interpretation,  and  it  is  evident  that  he  at- 
tributed the  inguinal  enlargements  to  the  matter  secreted  by  the 
ulcers,  although  the  extension  of  the  disease  may  now  be  differently 
and  more  satisfactorily  explained.  In  Vidal  we  find,  that  in  conse- 
quence of  disease  resulting  from  intercourse  with  the  prostitutes  of 
London,  certain  regulations  were  adopted  before  the  beginning  of  the 
fifteenth  century.  Although  many  other  well-authenticated  facts 
might  be  adduced,  I  consider  these  sufficient  to  establish  the  exist- 
ence of  the  disease  in  Europe  many  centuries  before  the  discovery  of 
America;  but  it  cannot  be  denied  that  about  that  time  it  acquired 
an  activity  and  malignity  which  was  before  unknown,  and  produced 
not  only  the  greatest  consternation,  but  also  directed  the  attention  of 
physicians  especially  to  the  subject.  All  the  symptoms  were  then 
carefully  observed,  the  varieties  accurately  described,  and  a  methodi- 
cal and  specific  treatment  recommended,  which  accounts  satisfactorily 
for  a  majority  of  medical  writers  having  agreed  upon  the  fifteenth 
century  as  the  date  of  its  origin.  If  no  evidence  existed  of  its  preva- 
lence previous  to  that  period,  the  conclusion  that  it  was  an  evil  im- 
posed upon  civilization  by  the  savages  of  a  distant  country,  who  were 
themselves  at  that  time  ignorant  of  the  disease,  was  not  only  gratify- 
ing to  their  pride,  but  also  a  very  plausible  excuse  for  their  igno- 
rance of  the  peculiarities  of  a  disease  with  which  they  should  have 
been  familiar.  If  the  acquisition  and  spread  of  syphilis  was  a  neces- 
sary consequence  of  the  most  brilliant  discovery  that  was  ever 
achieved,  both  in  its  conception  and  accomplishment,  it  would  have 
been  better  if  the  continent  of  America  had  remained  in  the  posses- 
sion of  wild  beasts  and  savages,  and  that  civilization  had  not  ex- 
tended beyond  the  eastern  coast  of  the  Atlantic. 

In  1495,  when  Naples  was  occupied  by  the  French  army,  under 
the  command  of  Charles  VIII,  it  spread  with  such  alarming  rapid- 


LECTURE    XLIIT.  —  SYPHILIS    AND    ITS    TREATMENT.      441 

ity,  and  produced  such  extensive  ravages,  that  it  received  the  name 
of  the  epidemic  of  the  fifteenth  century.  In  1492,  Columbus  sailed 
from  Spain,  and  returned  in  1493,  and,  if  the  malady  had  been  con- 
tracted by  his  crew  on  the  islands  discovered,  it  would  have  been 
impossible  (admitting  that  they  returned  with  the  primary  and  con- 
tagious form  of  the  disease,  and  that  the  inhabitants  of  Europe  in- 
dulged in  the  most  indiscriminate  illicit  intercourse)  for  it  to  have 
spread  so  rapidly  as  to  become  a  fearful  epidemic  in  so  short  a 
period.  To  Fallopius  we  are  indebted  for  the  first  correct  and  ac- 
curate description  of  the  disease,  although  Fernel  deservedly  occu- 
pies the  front  rank  amongst  the  scientific  writers  upon  the  subject; 
he  described  both  the  local  and  constitutional  symptoms  so  faithfully 
and  accurately,  that  but  little  has  been  added  during  the  last  two 
centuries. 

For  twenty  years  the  primary  symptoms  engaged  the  attention  of 
the  profession  almost  exclusively,  and  it  was  not  until  the  year  1516 
that  Juan  de  Vigo  described  what  is  now  considered  the  tertiary  form 
of  the  disease;  Maynard  directed  the  attention  of  the  profession  to 
warts  and  excrescences  upon  the  vulva  and  penis  in  1530;  Fracas- 
tor  to  inguinal  bubo  in  1533;  Brassavole  and  Filippe  added  alopecia 
to  the  symptoms  already  known,  in  1551,  and  about  the  same  time 
engorgements  of  the  lymphatic  glands,  resulting  from  infiltration  of 
serum,  ringing  in  the  ears,  ophthalmia,  nocturnal  pains,  and  a  va- 
riety of  other  symptoms  were  added. 

When  the  venereal  virus  is  applied  to  a  mucous  membrane,  to  a 
part  deprived  of  its  cuticle,  or  sometimes  to  the  healthy  skin,  either 
a  redness,  excoriations,  chancre,  or,  as  some  suppose,  mucous  pustules, 
are  produced.  The  latter,  though  generally  regarded  as  a  primary 
affection,  I  have  always  considered  as  resulting  either  from  the  irri- 
tation of  a  gonorrhreal  discharge,  or  a  constitutional  affection,  and 
then  they  are  easily  distinguished  from  what  is  usually  considered  a 
simple  mucous  pustule.  A  disease  of  this  character  prevails  exten- 
sively amongst  the  negroes  of  the  South,  in  which  the  scrotum,  labia, 
and  thighs  are  covered  with  pustules  of  this  character,  from  which 
a  profuse  and  peculiarly  offensive  secretion  is  produced.  It  is  con- 
tagious, never  becomes  constitutional,  and  yields  readily  to  local 
treatment.  This  is  usually  called  Norfolk  itch — most  probably  from 
its  prevalence  in  that  locality. 

A  chancre  is  a  small   ulcer  produced  as  above  specified,  and  has 


442  LECTURES    ON    PRACTICAL    SURGERY. 

received  the  appellation  because  it  is  frequently  painful,  and  extends 
like  a  cancerous  ulceration.  This  definition,  however,  is  not  strictly 
true,  as  many  of  them  are  both  indolent  and  stationary.  They  are 
either  primitive  or  consecutive, — primitive  when  they  appear  very 
soon  after  the  application  of  the  poison,  and  consecutive  when  they 
reappear  after  several  weeks  have  elapsed.  Primitive  chancres  are 
located  at  the  point  where  the  virus  has  been  applied ;  the  period  of 
their  development  is  somewhat  uncertain,  varying  from  twelve  hours 
to  seven  or  eight  days. 

Consecutive  chancres  are  always  produced  at  a  considerable  distance 
from  the  point  occupied  by  the  primary  ulcer,  and  are  not  developed 
in  less  than  forty  days  after  the  disease  is  contracted.  They  are  gen- 
erally situated  upon  the  mucous  membranes  near  the  external  surface 
of  the  body,  as  upon  the  glans  penis  and  prepuce  in  the  male,  and 
upon  the  external  surface  of  the  labia,  the  clitoris,  or  entrance  of  the 
vagina  in  the  female.  They  are,  however,  often  seen  upon  the  eye- 
lids, lips,  mammae,  under  the  arms,  on  the  perineum,  scrotum,  fin- 
gers, and  toes,  and  indeed  wherever  the  skin  is  not  usually  very  dry. 

I  have  seen  in  the  United  States  Marine  Hospital,  in  San  Fran- 
cisco, an  ulcer  upon  the  upper  eyelid,  which  presented  all  the  char- 
acteristics of  a  genuine  Hunterian  chancre.  Another,  equally  well 
marked,  was  seen  near  the  root  of  the  nail  of  the  right  index  finger; 
both  of  these  had  resisted  the  ordinary  remedies,  and  were  followed 
by  secondary  symptoms,  but  yielded  readily  to  mercurial  treatment. 
Chancres  upon  the  lips,  nose,  and  mammsa  are  so  common  that 
every  physician  engaged  in  practice  must  have  met  with  cases  so 
decided  in  their  character  that  they  could  not  be  mistaken.  Chan- 
cres at  the  commencement  present  small,  red,  and  elevated  points, 
which  are  usually  accompanied  with  an  inconvenient  pruritus.  The 
centre  becomes  rapidly  elevated,  whitish,  vesicular,  and  transparent, 
and  emits  a  reddish  and  acrid  serosity ;  very  soon  the  summit  of  the 
elevation  disappears,  and  an  excavation  is  manifest.  The  edges,  from 
the  loss  of  substance  resulting  from  the  progressive  ulceration,  be- 
come elevated,  frequently  indurated,  and  the  ulcerated  surface  secretes 
a  fetid  and  more  or  less  abundant  purulent  matter.  In  other  cases, 
from  the  activity  of  the  poison,  the  affected  part  becomes  deeply  ul- 
cerated before  the  patient  is  conscious  of  the  existence  of  any  serious 
derangement. 

Sometimes  chancres  present  the  appearance  of  a  simple  excoriation, 


LECTURE    XLIII.  —  SYPHILIS    AND    ITS    TREATMENT.       443 

which  gradually  extends  until  it  presents  all  the  peculiarities  of 
syphilitic  ulcers. 

Frequently,  in  California,  in  a  few  days  after  exposure,  both  the 
glans  penis  and  inner  surface  of  the  prepuce  exhibit  a  continuous 
excoriated  surface,  with  a  few  points  of  ulceration.  This  form  of 
the  disease  is  most  commonly  observed  after  intercourse  with  the 
Chinese  prostitutes,  who  are  so  numerous  in  this  city,  and  who  seem 
to  have  modified  the  disease  very  materially,  as  an  ordinary  chancre 
seldom  results  from  such  exposure. 

In  other  cases  the  skin  covering  the  penis,  most  commonly  pos- 
terior to  the  glans,  inflames  and  becomes  painful,  suppuration  takes 
place  in  the  subcutaneous  cellular  tissue,  and  when  the  integument 
either  ulcerates  or  an  incision  is  made  for  the  evacuation  of  the  pus, 
it  speedily  assumes  all  the  peculiarities  of  a  genuine  chancre.  Some- 
times these  exist  alone,  and  occasionally  chancres  appear  simultane- 
ously upon  the  prepuce  and  glans  penis.  The  surface  of  a  syphilitic 
ulcer  generally  presents  a  grayish-white  color.  The  edges  are  more 
or  less  perpendicular,  elevated,  and  surrounded  by  a  reddish  margin. 
Chancres  of  this  character  are  usually  followed  by  buboes,  which 
depends  either  on  the  inflammation  extending  to  the  neighboring 
lymphatic  glands  or  upon  the  absorption  of  the  virus. 

Chancres  differ  in  character,  are  accompanied  by  a  greater  or  less 
degree  of  inflammation,  and,  consequently,  are  divided  into  mild  or 
indolent,  painful  or  inflammatory.  Some  primitive  and  almost  all 
consecutive  chancres  are  indolent,  although  a  majority  of  the  former 
are  decidedly  inflammatory,  and  are  frequently  accompanied  either 
with  phimosis  or  paraphimosis. 

The  progress  of  chancres  is  as  different  as  their  character,  and  they 
are  divided  into  stationary,  phagedenic,  and  serpiginous. 

The  varieties  in  shape  or  form  which  they  present  are  not  less  de- 
cided ;  generally  they  are  round  or  oval,  although  many  irregulari- 
ties are  observed,  and  the  character  of  an  ulcer  upon  the  genital 
organs  cannot  always  be  determined,  either  by  its  shape  or  appear- 
ance, as  many  aggravated  constitutional  symptoms  frequently  result 
from  ulcers  that  heal  readily  and  present  none  of  the  characteristics 
of  a  Hunterian  character. 

Treatment. — I  will  next  present  for  your  consideration  the  means 
which  have  been  found  to  exert  a  controlling  influence  over  the 
primary  manifestations  of  this  rebellious  disease. 


444  LECTURES    ON    PRACTICAL    SURGERY. 

When  an  ulcer  presents  the  appearance  which  I  have  just  described 
4to  you,  and  succeeds  a  suspicious  connection,  and  even  when  ap- 
parently a  simple  ulcer  results  under  such  circumstances,  it  should 
be  regarded  as  syphilitic,  as  no  injury  can  possibly  result  from  a 
properly  regulated  mercurial  course  being  continued  until  its  char- 
acter can  be  positively  determined,  and  much  inconvenience  and 
suffering  might  be  inflicted  if  a  different  course  were  adopted. 

In  order  that  you  may  not  misconstrue  the  foregoing  remarks  in 
reference  to  doubtful  ulcerations,  I  will  mention  that  those  resulting 
from  herpes  preputialis  are  not  included,  as  they  are  easily  dis- 
tinguished from  every  variety  of  chancre,  and  in  such  cases  no 
necessity  exists  for  specific  treatment,  although  hundreds  are  treated 
as  syphilitic,  and  the  constitution  of  the  patients  destroyed  by  re- 
peated mercurial  courses,  rendered  necessary,  as  is  supposed,  by  the 
return  of  the  disease.  Herpetic  vesicles  generally  appear  in  clusters ; 
when  the  serum  escapes  a  scab  forms  upon  each,  and  if  proper  at- 
tention to  cleanliness  is  observed,  they  disappear,  to  return  with  the 
cause  by  which  they  were  originally  produced.  They  frequently 
result  from  irritation  of  the  urethra,  although  they  often  occur  with- 
out the  existence  of  any  appreciable  cause.  The  application  of  nitric 
acid  or  MonsePs  salt  promptly  effects  their  cure. 

The  local  treatment  of  chancre  should  vary  with  the  character  of 
the  disease  and  its  complications. 

Simple  Chancres. — In  the  simple  venereal  ulcer,  a  great  many 
remedies  are  recommended.  Some  prefer  mild  and  unirritating 
substances,  such  as  a  decoction  of  marshmallow  and  flaxseed  ;  others 
prefer  simple  cerate,  aquaB  calcis,  or  Van  Swieten's  liquor,  more  or 
less  diluted  with  vinum  opii  compositum.  When  the  sore  becomes 
indolent,  nitrate  of  silver  or  sulphate  of  copper  is  considered 
necessary.  The  abortive  treatment  is  sometimes  preferred,  which 
consists  in  the  application  of  nitrate  of  silver  as  soon  as  the  chancre 
is  discovered,  for  the  purpose  of  preventing  the  absorption  of  the 
virus,  and  thereby  removing  the  necessity  of  constitutional  treat- 
ment. Lagneau  is  decidedly  opposed  to  this  proceeding,  because  it 
increases  the  liability  of  the  formation  of  bubo,  and  frequently 
induces  the  patient  to  discontinue  the  specific  treatment  before  the 
virus  is  eradicated  from  the  system. 

Inflammatory  Chancres. — General  and  local .  abstraction  of  blood, 
rest,  laxatives,  and  low  diet  are  recommended.  In  some  cases,  every 


LECTURE    XLIII.  —  SYPHILIS    AND    ITS    TREATMENT.      445 

method  of  treatment  fails,  and  gangrene  supervenes,  produced  by 
the  distension  of  the  part,  necessarily  resulting  from  excessive 
inflammation.  In  California,  sloughing  chancres  are  very  common, 
and  can  usually  be  traced  to  the  injudicious  application  of  local 
irritants,  to  inattention  to  cleanliness,  or  to  intemperance.  During 
the  two  years  that  I  had  charge  of  the  United  States  Marine  Hospi- 
tal,  many  cases  of  this  description  were  treated  in  that  institution. 
Special  attention  should  be  paid  to  the  constitutional  derangement 
which  generally  accompanies  this  form  of  the  disease.  The  local 
application  which  I  have  found  most  effectual  in  arresting  the  prog- 
ress of  the  disease  is  nitric  acid.  In  order  that  the  application 
may  have  the  best  possible  effects,  there  are  a  few  details  to  which  I 
will  now  direct  your  attention.  It  should  be  applied  to  the  diseased 
surface  by  means  of  a  small,  soft  stick  of  wood,  which  should  be 
dipped  into  the  acid  and  then  brought  into  contact  with  the  ulcerated 
surfaces.  In  a  minute  the  surplus  acid  should  be  washed  off,  either 
with  a  strong  solution  of  the  supercarbonate  of  soda  or  by  means 
of  a  small  stream  of  water  from  a  faucet  to  which  a  piece  of  rubber 
tubing  may  be  attached,  thus  rendering  the  stream  more  manageable. 
A  dressing  should  then  be  applied,  consisting  of  simple  cerate  spread 
upon  a  piece  of  lint  just  large  enough  to  cover  the  ulcerated  sur- 
face. The  prepuce  should  then  be  brought  over  the  glans  penis. 

A  constitutional  course  of  treatment  is  never  necessary  in  cases  of 
phagedenic  chancres,  as  the  sphacelation  appears  to  destroy,  or  at 
least  to  prevent,  the  absorption  of  the  virus.  Malignant  chancres, 
which  are  painful  and  not  violently  inflamed,  are  either  phagedenic 
or  serpiginous.  The  first  extend  rapidly  in  depth  and  circumference, 
and  cause  extensive  destruction  both  of  the  skin  and  subcutaneous 
cellular  tissue.  Serpiginous  chancres  are  much  less  dangerous,  and 
heal  on  one  side  whilst  they  extend  on  the  other.  They  are  known 
by  their  hard,  elevated,  and  bleeding  edges,  have  ash-colored  surfaces, 
and  are  covered  with  eschars.  In  phagedenic  and  serpiginous  chan- 
cres, you  will  find  the  local  application  of  nitric  acid  the  most  reli- 
able remedy— one  application  being  frequently  sufficient  to  arrest  the 
progress  of  the  disease  and  change  the  character  of  a  rapidly  spread- 
ing or  obstinate  chancre  into  a  healthy,  granulating  surface.  Should 
you,  after  two  or  three  applications  of  the  nitric  acid,  find  that  there 
is  a  tendency  to  haemorrhage,  or  that  healthy  granulations  do  not 
promptly  appear,  then  the  best  application  to  make  is  the  powdered 


446         LECTURES  ON  PRACTICAL  SURGERY. 

subsulphate  of  iron  or  MonsePs  salt.  This  drug  not  only  checks 
the  bleeding  in  phagedenic  chancres,  which  is  sometimes  severe,  but 
it  also  exerts  a  most  salutary  influence  upon  the  ulcer,  promoting 
rapid  cicatrization,  and,  at  the  same  time,  acting  as  a  powerful  sor- 
befacient  by  reducing  the  swelling,  which  is  so  often  an  annoying 
complication  in  this  form  of  the  disease.  Before  the  salt  is  applied, 
the  crystals  should  be  broken,  which  can  be  accomplished  by  intro- 
ducing a  small,  dry  spatula  into  the  bottle,  and  revolving  it  until 
the  necessary  diminution  is  effected.  The  bottles  containing  it 
should  be  small,  in  consequence  of  its  great  deliquescence,  and  the 
air  should  be  carefully  excluded.  It  should  be  applied  freely  once 
every  twenty-four  hours,  in  cases  where  its  effects  are  desired,  for 
unless  carefully  and  properly  used,  you  may  fail  to  obtain  the  favor- 
able results  which  I  have  so  often  witnessed. 


LECTURE  XLIV.  —  TREATMENT  OF  PRIMARY  SYPHILIS.  447 


LECTURE    3 

CONSTITUTIONAL   TREATMENT   OF   PRIMARY   SYPHILIS'. J 

GENTLEMEN  :  In  the  last  lecture  I  described  to  you  the  method 
of  detecting  the  initial  lesion  of  syphilis,  together  with  the  plan  of 
treatment  which  I  have  found  most  efficacious  in  the  management 
of  the  local  derangement.  It  now  remains  for  me  to  present  to  you 
the  internal  or  constitutional  remedies,  which  you  will  find  to  be  a 
most  important  adjuvant  to  the  local  treatment. 

Before,  and  even  many  years  after,  the  work  of  the  celebrated 
John  Hunter  appeared  upon  this  disease,  in  1786,  many  physicians 
not  only  denied  the  existence  of  a  specific  poison,  but  also  contended 
that  neither  chancres  nor  any  of  the  varieties  of  syphilitic  ulcers  re- 
quired a  different  treatment  from  that  usually  employed  to  control 
either  simple  inflammation,  irritation,  or  ulceration  upon  other  por- 
tions of  the  body.  The  fact  that  Rose,  G.  J.  Guthrie,  Fergusson, 
Hennen,  and  McGregor,  distinguished  surgeons  of  the  British  army, 
as  well  as  Hill,  Bartlett,  and  Turner,  of  Edinburgh,  and  Carmichael, 
of  Dublin,  advocated  this  doctrine,  is  very  astonishing,  and  can  only 
be  attributed  to  a  want  of  sufficient  experience  to  enable  them  to 
determine  the  comparative  efficacy  of  the  various  methods  of  treat- 
ment that  were  then  employed. 

Notwithstanding  the  influence  necessarily  exerted  by  such  high 
authority,  the  doctrine  they  advocated,  not  being  sustained  by  ex- 
perience, was  neither  so  popular,  nor  the  anti-mercurial  treatment 
so  strongly  supported,  nor  so  generally  adopted  in  England,  as  it 
was  subsequently  in  France.  In  1697,  Sinapicis  announced  that 
there  was  no  such  disease  as  syphilis,  and  he  was  sustained  by  some 
of  the  most  celebrated  members  of  the  faculty.  Jourdan,  Richard, 
Deverrais,  Lefevre,  and  Dubled  contended  that  all  inflammations 
were  not  only  identical  in  their  character,  but  also  that  their  peculi- 
arities depended  entirely  upon  the  tissues  in  which  they  were  de- 
veloped, or  upon  their  greater  or  less  intensity,  and  not  upon  the 
specific  irritation  by  which  they  were  produced. 


448  LECTURES'  ON    PRACTICAL    SURGERY. 

A  distinguished  professor  of  Montpellier,  in  order  to  determine 
positively  by  experiment  the  curability  of  chancre  without  the  use 
of  mercury,  selected  a  hundred  recent  cases,  with  the  following 
results:  The  local  symptoms  disappeared  in  ninety  by  the  employ- 
ment of  the  ordinary  antiphlogistic  treatment.  Only  ten  cases,  in 
which  the  secondary  symptoms  appeared  soon  after  the  primary 
ulcers  healed,  were  relieved,  and  in  them,  when  the  disease  assumed 
the  tertiary  form,  although  subjected  to  the  same  treatment,  it  was 
successful  apparently  only  in  three,  even  in  the  first  stage,  and  was 
entirely  inefficacious  after  the  system  became  thoroughly  saturated 
with  the  poison. 

Although  the  result  of  these  experiments  was  of  the  most  positive 
character,  a  long  period  elapsed  before  the  mercurial  treatment  was 
generally  adopted,  even  by  scientific  physicians.  This  depended 
upon  the  abuse  of  the  remedy,  and  its  administration  being  generally 
accompanied  by  purgatives  and  low  diet,  by  which  the  system  was 
so  much  enfeebled  that  the  disease  progressed  with  greater  rapidity 
than  when  entirely  neglected.  The  symptoms  resulting  from  the 
progress  of  the  disease  were  very  improperly  attributed  to  the  poison- 
ous properties  of  the  remedy.  Even  as  late  as  1833,  many  physicians 
in  Paris  were  unwilling  to  admit  either  the  existence  of  a  specific 
poison  or  the  superiority  of  the  mercurial  treatment;  but  now  no 
difference  exists  between  the  respectable  and  worthy  members  of  the 
profession,  consequently  the  relative  value  of  the  different  mercurial 
preparations  remains  only  to  be  determined. 

It  is  generally  admitted  that  crude  mercury,  when  administered 
internally,  is  comparatively  inert  by  reason  of  its  insolubility,  and 
in  order  to  render  it  active,  it  becomes  necessary  to  subject  it  to  trit- 
uration,  calcination,  or  the  action  of  acids.  Boerhaave,  of  Leyden, 
and  Saunders  reduced  it  to  a"  powder  by  agitation,  and  administered 
it  in  that  form,  which,  although  sufficiently  active,  requires  so  much 
time  and  labor  for  its  accomplishment  that  other  preparations  are 
generally  preferred. 

When  crude  mercury  is  triturated  for  a  long  time  with  unctuous 
substances,  the  metal  is  changed,  and  a  very  convenient  and  active 
preparation  is  the  result,  which,  when  applied  externally,  produces 
the  constitutional  effect  of  the  remedy  as  speedily  as  it  can,  with 
entire  safety,  be  accomplished. 

If  combined  in  the  same  manner  with  either  gums,  mucilages,  or 


LECTURE  XLIV.  —  TREATMENT  OF  PRIMARY  SYPHILIS.     449 

saccharine  substances,  a  very  valuable  internal  remedy  is  obtained, 
which  was  formerly  more  extensively  employed  than  any  of  the 
other  numerous  preparations  of  the  mineral.  The  use  of  the  pilulae 
hydrargyri  is  not  restricted  to  the  treatment  of  this  disease,  but  is 
prescribed  whenever  it  is  necessary  to  administer  a  mild  laxative 
and  mercurial  alterative. 

The  proto  and  deutochlorides  of  mercury  are  produced  by  the 
combination  of  this  metal  with  muriatic  acid,  and  the  proto  and 
deutiodides  by  uniting  it  with  iodine;  the  latter  are  now  consid- 
ered among  the  most  valuable  of  all  the  mercurial  preparations  in 
the  treatment  of  primary  syphilis. .  Mercury  may  be  administered 
either  internally  or  externally,  and  externally  either  by  fumigation 
or  friction. 

When  a  syphilitic  ulcer  progresses  with  such  rapidity  as  to  defy 
the  action  of  the  ordinary  remedies,  particularly  when  situated  upon 
an  important  portion  of  the  body,  the  loss  of  which  would  produce 
either  permanent  deformity  or  impotency,  fumigation  should  be  em- 
ployed. The  most  simple  and  convenient  method  of  obtaining  the 
full  effect  of  the  remedy  by  this  method  of  administration,  is  by 
throwing  cinnabar  or  Ethiops  mineral  upon  burning  charcoal  in  a 
close  room,  and  exposing  the  surface  of  the  body  to  the  action  of  the 
fumes  whilst  they  are  being  inhaled.  Should  their  inhalation  em- 
barrass respiration  seriously,  the  patient  may  be  allowed  to  breathe 
pure  air,  and  the  action  of  the  remedy  be  confined  to  the  external 
surface. 

A  patient,  even  if  the  symptoms  be  urgent,  should  not  be  exposed 
to  mercurial  fumigation  more  than  half  an  hour  morning  and  evening, 
as  salivation  is  frequently  very  speedily  produced,  and  if  injudici- 
ously employed,  the  effect  is  sometimes  very  alarming.  The  action 
of  this  remedy  being  transient,  nothing  more  should  be  expected 
from  it  than  to  arrest  the  progress  of  the  disease  until  other  more 
safe  and  manageable  preparations  have  time  to  exert  their  influence. 
In  1736,  Charbonnier  appeared  in  Paris,  and  professed  to  cure  every 
variety  of  the  disease  by  fumigation,  administered  so  as  to  be  not- 
only  safe,  but  also  easily  controlled.  The  expectations  excited  by 
this  announcement  not  being  fully  realized  by  the  profession,  it  was- 
abandoned  until  1776,  when  Laborrette  published  that  he  had  dis- 
covered a  new  method  of  employing  fumigation,  which  was  uni- 
versally applicable.  Abernethy  adopted  his  treatment  in  some  cases,, 

29 


450  LECTURES    ON    PRACTICAL    SURGERY. 

and  was  satisfied  with  the  result.  As  time  determines  the  value  of 
every  remedy,  this  is  now  only  resorted  to  in  obstinate  and  malignant 
syphilitic  affections,  in  consequence  of  the  difficulty  experienced  in 
controlling  its  action.  Bell  thinks  that  great  benefit  may  be  de- 
rived in  obstinate  syphilitic  ulcers  by  the  local  effect  of  fumigation, 
as  they  frequently  assume  a  healthy  appearance  and  cicatrize  rapidly 
after  resisting  the  influence  of  other  treatment. 

The  red  oxide  of  mercury  was  a  favorite  remedy  of  Hunter,  which, 
although  very  efficacious,  is  now  rarely  prescribed  in  consequence  of 
the  expense  and  difficulty  attending  its  preparation. 

Bell,  the  author  of  one  of  the  best  works  published  during  the 
last  century,  preferred  the  endermic  application  of  mercury,  and 
thought  that  in  general  practice  it  should  be  preferred.  From  one 
to  two  drachms  of  the  uuguentum  hydrargyri  may  be  employed 
daily,  and  thirty  minutes  should  be  consumed  in  making  the  appli- 
cation. He  was  induced  to  adopt  this  method  of  treatment  in  con- 
sequence of  the  effect  of  all  mercurial  preparations,  when  taken 
internally  and  long  continued,  upon  the  stomach  and  bowels. 

Marjolin,  who  was  one  of  the  ablest  professors  of  surgery  in  the 
school  of  medicine  in  Paris,  advocated  in  the  strongest  terms  this 
treatment  in  primary  syphilis,  because  he  believed  it  to  be  superior 
to  any  that  could  be  adopted.  He  stated  in  his  lectures  that  he  had 
observed  carefully  the  result  of  every  course  of  treatment  that  had  until 
that  time  been  recommended,  and  was  convinced  that  the  endermic 
application  of  the  unguentum  hydrargyri  was  the  most  certain  and 
expeditious  method  of  not  only  removing  the  local  affection,  but  also 
of  securing  the  patient  against  constitutional  symptoms. 

Lagneau,  the  most  distinguished  writer  upon  syphilis  at  that  time 
in  France,  pursued  the  same  course  of  treatment  which  was  recom- 
mended and  so  ably  supported  by  Marjolin.  From  the  authorities 
which  I  have  just  quoted,  as  well  as  from  my  own  experience  of  this 
treatment,  I  am  convinced  that  it  is  now  undeservedly  neglected, 
which  results  both  from  the  inconvenience  of  its  application  and  the 
great  anxiety  of  professional  men  to  avail  themselves  of  new  reme- 
dies, to  the  abandonment  of  those  of  long-established  and  merited 
reputation. 

Internal  Remedies. — Although  formerly  very  numerous,  the  in- 
ternal remedies  used  in  this  disease  have  not,  all  of  them,  stood  the 
test  of  experience.  Bell,  Pearson,  and  Ricord,  many  years  ago,  pre- 


LECTURE  XLIV.  —  TREATMENT  OF  PRIMARY  SYPHILIS.     451 

ferred  the  pilulse  hydrargyri  to  any  other  preparation,  because,  ad- 
ministered in  this  form,  the  mercury  produced  less  derangement  of 
the  stomach  and  bowels  than  many  of  its  more  active  compounds. 
It  may  be  given  in  four-grain  doses,  three  times  daily,  and  should 
the  bowels  become  too  active  during  its  administration,  it  may  be 
combined  with  a  sufficient  quantity  of  opium  to  obviate  that  effect, 
which  renders  it  not  only  a  very  safe  and  manageable  but  also  an 
exceedingly  valuable  preparation,  in  both  primary  and  secondary 
affections. 

The  protochloride  of  mercury  is  now  not  much  used  in  England, 
France,  or  the  United  States,  although  when  carefully  prescribed, 
the  specific  effect  of  the  mercurial  preparation  may  be  both  readily 
and  safely  obtained.  It  is,  however,  decidedly  purgative,  and  pro- 
duces ptyalism  more  speedily  than  any  other  internal  remedy,  which 
is  a  very  grave  objection,  particularly  since  it  has  been  positively 
ascertained  that  the  specific  action  of  mercury  upon  the  salivary 
glands  is  not  necessary  to  obtain  its  constitutional  effect. 

The  deutochloride  of  mercury,  although  discovered  by  Basil 
Valentine,  was  brought  into  general  use  by  Van  Swieten,  and  is  still 
prescribed  and  highly  appreciated  in  every  portion  of  Europe,  as 
well  as  in  the  United  States.  Being  easily  disguised  and  not 
likely  to  salivate,  it  is  supposed  to  form  the  basis  of  all  the  quack 
remedies  now  employed.  Dupuytren  preferred  this  preparation, 
although  it  is  generally  conceded  to  be  more  valuable  in  the  tertiary 
than  in  the  primary  stage  of  the  disease.  Dr.  Locher  cured  nearly 
five  thousand  cases  in  the  Vienna  Hospital  from  1754  to  1762  with 
this  preparation  without  salivating  a  single  patient,  and  during  the 
present  century  it  was  preferred  and  employed  by  both  Drs.  Hosack 
and  Francis  of  our  own  country.  It  may  be  given  in  doses  of  one- 
sixth  of  a  grain,  three  times  daily,  either  in  pill  or  solution,  with 
or  without  opium,  as  may  be  necessary. 

Having  carefully  observed  the  effect  of  the  mercurial  preparations 
now  employed  in  the  treatment  of  primary  syphilis,  and  having  ex- 
perimented extensively  with  the  view  of  determining  their  compara- 
tive efficacy,  whilst  connected  with  the  public  institutions  of  this  city, 
I  am  convinced  that  Ricord's  favorite  remedy,  the  protiodide  of 
mercury,  is  preferable  to  any  other  preparation,  and  that  the  length 
of  time  it  is  administered  is  of  more  consequence  than  the  quantity 
prescribed.  I  usually  give  it  in  such  doses  as  produce  little  or  no 


452  LECTURES    ON    PRACTICAL    SURGERY. 

derangement  of  the  stomach  or  irritation  of  the  bowels,  and  continue 
it  sufficiently  long  to  prevent  the  possibility  of  the  occurrence  of 
secondary  symptoms. 

Dupuytren  recommended  the  mercurial  treatment  to  be  continued 
as  long  as  found  necessary  to  cure  the  primary  ulcers.  Some  think 
twenty  or  thirty  days  sufficient  to  eradicate  the  virus  ;  but  I  am  sat- 
isfied that  in  aggravated  cases  it  should  be  continued  two  months  at 
least,  and  should  this  course  be  adopted,  our  public  hospitals  would 
not  be  crowded  with  patients  suffering  from  every  variety  of  consti- 
tutional syphilis. 

The  following  formula,  I  have  found  both  efficacious  and  manage- 
able: 

R. — Hydrargyri  protiodidi,         ...         .     grs.  xx. 
Gum.  opii,   .......     grs.  x. 

Extracti  cicutae, grs.  xl. 

M.     Ft.  pilulse  No.  xl. 

One  of  these  should  be  taken  three  times  a  day.  The  chancre,  by 
the  aid  of  the  local  treatment  which  I  described  to  you  in  the  pre- 
vious lecture,  generally  disappears  rapidly,  without  any  other  sensi- 
ble effect  being  produced.  Occasionally  sickness  of  the  stomach,  loss 
of  appetite,  and  irritation  of  the  bowels  occur,  and  then  pil.  hy- 
drargyri  combined  with  opium  and  cicuta  should  be  substituted.  If, 
however,  the  internal  administration  of  mercury  proves  obnoxious 
to  the  patient,  it  should  be  applied  endermically,  and  accompanied 
with  the  decoction  of  sarsaparilla,  guaiac,  and  sassafras,  for  the  pur- 
pose of  increasing  the  activity  of  the  digestive  organs,  and  thereby 
improving  the  tone  and  vigor  of  the  general  system. 

In  scrofulous  subjects,  even  in  the  primary  form  of  the  disease, 
the  deutochloride  of  mercury  should  be  preferred,  in  combination 
with  the  iodide  of  potassium,  to  counteract  the  strumous  tendency, 
which  is  always  increased  by  the  long-continued  use  of  a  remedy  so 
decidedly  debilitating  as  are  even  the  mildest  preparations  of  mer- 
cury. 

The  following  combination,  I  have  found  to  be  not  only  effica- 
cious, but  greatly  superior  to  any  other  that  has  been  employed  : 

R. — Hydrargyri  chloridi  corrosivi,        .         .         .     gr.  j. 
Potassii  iodidi,        .....       givtogv. 
Tincturse  aconiti  radicis,         ....        spss. 
Extracti  stillingia3  sylvaticae, 

Syrupi  sarsse  compositi,  aa  .         .         .          !f  iiss. 

M.     Sig. — Take  one  teaspoonful,  three  times  a  day  in  water. 


LECTURE    XLIV.  —  TREATMENT    OF    PRIMARY    SYPHILIS.     453 

The  solution  of  iodide  of  potassium  in  the  mixture  being  in  ex- 
cess, after  the  necessary  chemical  changes  occur,  biniodide  of  mer- 
cury in  a  solution  of  iodide  of  potassium  is  produced.  The  syrup 
of  sarsaparilla  is  only  used  to  disguise  the  other  ingredients,  and  the 
extract  of  stillingia  is  used  in  consequence  of  its  antisyphilitic  and 
antistruraous  properties.  In  the  Southern  Atlantic  States  it  is  ex- 
tensively used  in  such  cases,  and  by  many  is  relied  upon  exclusively 
in  their  treatment.  To  Robert  Y.  Simmons,  of  Charleston,  South 
Carolina,  is  due  the  credit  of  directing  the  attention  of  the  profes- 
sion to  this  very  useful  article.  The  extract  of  stillingia,  being  un- 
pleasant to  the  taste,  sometimes  produces  sickness  of  the  stomach  and 
even  vomiting,  which  renders  it  necessary  that  it  should  be  discon- 
tinued, it  being  very  important  to  give  special  attention  to  the  diges- 
tive organs,  for  upon  their  activity,  in  many  cases,  depends  the 
safety  of  the  patient.  During  the  use  of  this  or  of  any  other  prepara- 
tion containing  mercury,  so  soon  as  evidences  of  general  debility  be- 
come manifest,  it  should  be  either  suspended  or  continued  in  minute 
doses,  in  combination  with  tonics,  either  vegetable  or  mineral. 

Notwithstanding  the  opinion  recently  advanced  and  apparently 
sustained  by  those  worthy  of  confidence,  that  simple  chancres  are 
never  followed  by  constitutional  symptoms,  a  mercurial  course 
should  invariably  be  prescribed,  the  necessity  of  which  will  be  more 
fully  demonstrated  when  we  come  to  the  treatment  of  secondary  af- 
fections. I  have  repeatedly  seen  a  simple  chancre  that  was  healed 
in  a  few  days  by  mild  local  applications,  followed  by  the  most 
serious  constitutional  symptoms.  Moreover,  I  am  perfectly  satisfied 
that  they  are  more  dangerous  than  those  of  a  malignant  character, 
as  the  treatment  is  not  adopted  by  which  alone  the  system  can  be 
protected.  A  professional  friend  in  this  city,  some  time  ago,  treated 
a  case  of  inflammatory  indurated  chancre,  communicated  by  a  patient 
under  his  care,  with  apparently  a  simple  ulcer,  and  who  assured 
him  that  he  had  never  before  had  any  form  of  venereal  disease. 

I  have  also  repeatedly  met  with  patients  in  the  United  States 
Marine  Hospital  in  San  Francisco,  with  secondary  syphilis,  who 
presented  evidences  of  having  previously  suffered  seriously  from  the 
same  form  of  disease. 

That  ulcers  frequently  appear  upon  the  genital  organs,  yield  to 
simple  treatment,  and  are  not  followed  by  any  constitutional  affec- 
tion, cannot  be  denied.  In  such  cases,  it  is  more  than  probable  that 


454          LECTURES  ON  PRACTICAL  SURGERY. 

they  are  not  produced  by  impure  intercourse,  and  result  from  sim- 
ple irritation,  which  would  produce  a  similar  difficulty  upon  any 
other  portion  of  the  body.  Although  I  have  observed  the  ulcers 
that  appear  upon  the  genital  organs  closely,  watched  their  pro- 
gress daily,  and  have  endeavored  to  familiarize  myself  with  their 
aspect  and  peculiarities,  yet  I  must  confess  that  in  some  cases  I 
cannot  determine  positively  their  true  character.  Therefore,  when 
doubt  exists,  I  have  always  prescribed  a  mercurial  course,  to  secure 
the  patient  from  the  consequences  of  this  most  obstinate,  complicated, 
and  unmanageable  disease. 

Although  the  greatest  care  is  taken  in  the  administration  of  mer- 
cury, even  in  its  mildest  forms,  when  an  extraordinary  susceptibility 
to  its  action  exists  excessive  salivation  is  sometimes  produced,  which 
is  much  more  troublesome  during  its  continuance  than  the  disease 
for  which  the  drug  was  prescribed. 

A  great  variety  of  remedies  have  been  recommended  to  counter- 
act the  specific  action  of  mercury  upon  the  mouth  and  salivary 
glands.  Sulphur  was  formerly  regarded  as  a  specific,  although  it  is 
now  but  seldom  administered,  having  yielded  to  the  iodide  of  potas- 
sium, which  is  preferred  because  it  combines  with  the  metal  and  fa- 
cilitates its  elimination  from  the  system.  Although  valuable,  this 
preparation  is  inferior  to  the  chlorate  of  potassium  as  a  general 
remedy,  Sij  of  which  should  be  suspended  in  four  ounces  of  simple 
syrup,  and  administered  in  dessertspoonful  doses  every  two  hours 
during  the  day.  This,  with  the  application  of  nitrate  of  silver  to 
the  ulcers,  will  be  found  to  remove  ptyalism  more  speedily  than  any 
other  treatment.  When  the  secretion  of  saliva  is  profuse,  it  may  be 
temporarily  arrested  by  any  of  the  preparations  of  opium,  which 
should  be  administered  at  night. 

As  soon  as  ptyalism  begins  to  subside,  the  deutochloride  of  mer- 
cury should  be  preferred  to  any  other  preparation,  and  by  combining 
it  with  the  iodide  of  potassium,  it  may  be  given  sufficiently  long  to 
eradicate  the  virus  without  subjecting  the  patient  to  a  recurrence  of 
the  disease.  After  the  subsidence  of  the  febrile  symptoms  in  the 
inflammatory  form  of  primary  syphilis,  mercurials  should  be  pre- 
scribed, and  a  generous  diet  allowed,  to  counteract  the  debilitating 
effect  of  the  remedy.  Milk  is  the  only  article  in  common  use  that 
should  be  prohibited,  as  it  does  unquestionably  counteract  the  specific 
action  of  all  the  mercurial  preparations. 


LECTURE    XLV.  —  BUBO.  455 


LECTURE    XLV. 

BUBO. 

GENTLEMEN:  Syphilitic  bubo  is  a  painful  swelling  or  tumor 
resulting  from  an  enlargement  of  a  lymphatic  ganglion,  either  of  the 
groin,  neck,  or  armpit,  produced  by  the  absorption  of  the  venereal 
virus. 

Nicholas  Massa  designated  it,  in  1532,  "aposthema  inguinum," 
and  Marcel  de  Como,  the  first  writer  upon  this  disease,  not  only  de- 
scribes bubo  with  sufficient  accuracy,  but  also  attributes  it  to  the 
proper  cause — "Ego  Marcellus  Comanus  infinites  bubones  causatos 
ex  pustulis  virgse  euravi." 

Syphilitic  bubo  is  either  primitive,  consecutive,  or  constitutional. 
Primitive  bubo  appears  without  being  preceded  by  a  chancre,  and 
begins  to  develop  from  the  third  to  the  sixth  day.  That  the  vene- 
real virus  is  capable  of  being  absorbed,  and  affects  the  ganglia 
without  producing  either  irritation  or  ulceration  at  the  point  of 
application,  was  long  denied  by  many  whose  opinion  upon  any  sub- 
ject was  worthy  of  the  greatest  confidence.  Careful  observation  has, 
however,  determined  this  question  positively.  I  have  repeatedly 
seen  buboes  appear  without  being  preceded  by  the  slightest  abrasion 
of  either  the  skin  or  mucous  membrane,  that  when  treated  as  simple 
gangl ionic  enlargements  were  followed  in  a  few  weeks  by  secondary 
symptoms. 

Consecutive  bubo  always  manifests  itself  some  time  after  the  ap- 
pearance of  the  primary  affection,  and  is  generally  located  in  the 
immediate  vicinity  of  the  ulcer  by  which  it  was  produced.  Some- 
times the  irritation  extends  from  the  chancre  up  the  side  of  the  penis 
to  the  nearest  ganglion,  which  accounts  for  a  bubo  being  developed 
near  the  pubis.  It  seldom  appears  before  the  eighth  or  tenth  day, 
and  frequently  not  until  the  chancre  heals,  and  the  patient  considers 
himself  entirely  cured. 

Constitutional  bubo  is  produced  by  consecutive  ulceration. 


456          LECTURES  ON  PRACTICAL  SURGERY. 

Buboes  are  divided  into  inflammatory  and  indolent.  The  first 
are  very  painful,  and  progress  rapidly  either  to  resolution  or  to  sup- 
puration. The  second  are  neither  painful  nor  accompanied  with 
discoloration  of  the  skin,  suppurate  rarely  and  with  difficulty,  and 
are  either  constitutional  or  complicated  with  scrofula,  when  they 
frequently  acquire  an  enormous  size,  and  are  exceedingly  obstinate. 

Inflammatory  buboes  are  generally  located  upon  the  same  side 
upon  which  the  chancre  appeared,  and  are  usually  indicative  of  a 
recent  affection. 

When  above  Poupart's  ligament  and  in  the  groin,  they  are  called 
inguinal;  when  below  Poupart's  ligament,  crural;  and  when  near 
the  pubis  they  receive  the  appellation  of  pubic. 

Although  they  are  easily  distinguished  from  other  tumors,  mis- 
takes of  a  very  serious  character  have  frequently  occurred,  which 
can  only  result  either  from  great  carelessness  or  excessive  ignorance. 
To  the  touch  they  differ  from  strangulated  inguinal  or  crural  hernia 
both  in  form  and  consistence,  and  are  not  accompanied  by  the  con- 
stitutional symptoms,  such  as  obstinate  vomiting,  small,  rapid  pulse, 
and  excessive  prostration,  inseparable  from  a  protracted  constriction 
of  even  the  smallest  portion  of  the  intestinal  canal.  They  may  be 
easily  distinguished  from  sympathetic  bubo  or  scrofulous  enlarge- 
ment of  the  lymphatic  ganglions,  by  the  history  of  the  case  and  the 
progress  of  their  development.  He  who  mistakes  a  bubo,  either  in- 
guinal, crural,  or  pubic,  for  any  other  tumor  that  may  appear  in  that 
region,  is  unworthy  of  the  title  he  has  assumed,  and  deserves  the 
consequences  that  must  inevitably  follow  a  false  diagnosis. 

Sometimes  only  a  single  ganglion  is  affected,  the  first  to  which  the 
virus  is  applied;  more  frequently,  however,  several  are  implicated, 
and  either  become  indolent,  or  progress  regularly  and  rapidly  to 
suppuration. 

Treatment. — Bubo  requires  the  same  constitutional  treatment  recom- 
mended for  primary  syphilis,  and  it  is  equally,  or  more  important 
to  sustain  the  vigor  of  the  system,  in  consequence  of  the  tendency  to 
the  development  of  obstinate  phagedenic  ulcers  after  the  purulent 
secretion  has  been  discharged.  In  combination  with  a  mild  mercu- 
rial course,  the  compound  decoction  of  sarsaparilla,  before  recom- 
mended, or  other  tonics,  should  be  administered.  The  oleum  jecoris 
aselli  is  frequently  recommended,  but  it  never  should  be  adminis- 
tered. In  such  cases  give  cream,  the  compound  decoction  of  sarsa- 


LECTURE    XLV.  —  BUBO.  457 

parilla,  with  either  brandy,  whisky,  port  wine,  or  Holland  gin. 
Much  depends  upon  the  judgment  of  the  physician  in  such  cases. 
The  object  in  every  case  should  be  to  obtain  a  speedy  and  permanent 
recovery,  which  cannot  occur  should  the  general  health  be  impaired. 

Local  Treatment. — When  the  ganglia  in  the  vicinity  of  a  chancre 
begin  to  enlarge,  an  effort  should  be  made  to  prevent  suppuration, 
and  for  that  purpose  the  best  local  application  is  a  solution  of  equal 
parts  of  tincture  of  iodine  and  tincture  of  arnica.  With  this  the  en- 
largement should  be  painted  morning  and  evening,  and  continued 
until  considerable  irritation  of  the  skin  is  produced.  Even  if  sup- 
puration should  occur,  in  consequence  of  the  progress  of  the  disease 
being  partially  controlled,  a  very  limited,  instead  of  extensive,  ab- 
scess will  result,  and  a  much  shorter  period  will  be  required  for  its 
cicatrization.  Mercurial  ointment  is  preferred  by  some,  although  I 
consider  it  greatly  inferior  to  the  application  which  I  have  recom- 
mended. 

When  the  ganglia  are  greatly  enlarged,  and  become  indolent, 
Birt's  blistering  fluid  is  the  best  counterirritant  that  can  be  em- 
ployed, and  should  be  used  as  often  as  the  irritation  subsides.  By 
the  application  of  this  remedy  the  engorgement  will  either  disappear 
or  suppuration  occur,  which  is  preferable  to  the  continuance  of  the 
engorgement.  In  these  cases,  pressure  made  by  the  application  of 
a  truss  has  been  highly  recommended,  although  in  my  hands  it  has 
been  much  less  efficacious  than  the  application  which  I  before  de- 
scribed. 

As  soon  as  fluctuation  is  manifested  a  bubo  should  be  opened,  for 
if  neglected  until  the  parietes  become  greatly  attenuated,  before  an 
incision  is  made  they  either  slough  or  are  destroyed  by  subsequent 
ulceration,  and  an  extensive  suppurating  surface  results,  which  may 
require  many  months  to  cicatrize.  When  the  contents  have  escaped 
a  tent  should  be  introduced  to  prevent  union  by  the  first  intention, 
which  is  very  likely  to  occur  if  the  skin  has  not  been  partially  de- 
stroyed by  the  process  of  absorption. 

After  a  bubo  has  been  opened  the  water-dressing  is  preferable  to 
any  other,  and  it  may  be  continued  until  the  cavity  is  filled  with 
granulations;  then  simple  cerate  should  be  substituted  to  facilitate 
cicatrization.  When  a  bubo  has  been  neglected  until  the  integument 
ulcerates,  and  the  opening  is  large,  it  should  be  filled  with  Monsel's 
salt  every  day,  not  only  that  it  may  heal  rapidly,  but  also  to  prevent 


458  LECTURES    ON    PRACTICAL  '  SURGERY. 

the  extension  of  the  ulcer,  which  frequently  occurs  under  the  ordi- 
nary treatment,  and  proves  both  obstinate  and  exceedingly  trouble- 
some. Phagedenic  ulcerations  of  the  groin  resulting  from  this  cause, 
particularly  when  the  general  health  is  either  impaired  when  the 
disease  is  contracted,  or  is  rendered  so  by  the  treatment  to  which  the 
patient  has  been  subjected,  frequently  progress  rapidly,  become  ex- 
cessively irritable,  with  elevated  and  indurated  edges,  and  are  then 
the  most  obstinate  and  unmanageable  of  all  the  varieties  of  syphilitic 
ulcerations,  and  frequently  require,  even  when  subjected  to  the  best- 
directed  efforts  of  the  physician  with  the  means  heretofore  employed, 
months  and  even  years  before  their  progress  can  be  arrested. 

The  constitutional  treatment  should  depend  upon  the  previous 
management  of  the  case  and  the  general  health  of  the  patient.  If 
mercurials  have  been  prescribed,  and  no  other  evidence  of  secondary 
symptoms  presents  itself,  particularly  if  the  system  be  debilitated,  we 
should  rely  upon  tonics,  narcotics,  and  stimulants,  with  generous 
diet.  But  if  no  constitutional  treatment  has  been  adopted,  the  deuto- 
chloride  of  mercury,  in  connection  with  opium,  and  iodide  of  potas- 
sium with  tonics,  should  be  prescribed,  and  continued  sufficiently 
long  to  eradicate  the  virus.  In  phagedenic  ulceration  a  great  variety 
of  local  remedies  have  been  recommended,  none  of  which,  however, 
seem  to  exert  their  accustomed  influence,  and  their  comparative  value 
can  only  be  determined  by  experiment.  In  order  to  illustrate  more 
fully  the  foregoing  remarks,  I  will  give  you  the  histories  of  a  few 
cases  of  this  description  which  have  been  under  my  observation. 

CASE  I. — A  patient,  aged  25  years,  and  in  good  health,  contracted 
syphilis  in  Sonora,  in  1850.  Under  the  treatment  prescribed  the 
chancres  healed,  but  the  ulceration  in  the  groin  extended  so  rapidly 
that  he  became  alarmed,  and  was  treated  both  in  Sacramento  and 
San  Francisco,  until  the  winter  of  1853,  without  obtaining  relief. 
When  my  attention  was  directed  to  the  case  the  ulcer  extended  from 
Poupart's  ligament  on  the  left  side,  nearly  to  the  umbilicus,  and  its 
transverse  diameter  was  four  or  five  inches.  He  was  then  suffering, 
not  only  from  an  extensive  phagedenic  ulcer,  but  also  from  enfeebled 
health,  produced  by  the  debilitating  influence  of  the  long-continued 
use  of  mercurials.  Iodide  of  potassium,  with  the  compound  decoc- 
tion of  sarsaparilla,  and  a  generous  diet,  were  prescribed ;  the  indu- 
rated and  irregular  edges  of  the  ulcer  were  removed,  and  its  character 


LECTURE    XLV.  —  BUBO.  459 

changed,  by  the  application  of  zinc  paste.  Under  the  influence  of 
chloroform  the  paste  was  applied  so  as  to  include  about  three  inches 
of  the  margin,  and  repeated  as  soon  as  he  recovered  from  the  consti- 
tutional disturbance  necessarily  produced  by  so  powerful  an  escha- 
rotic.  This  course  of  treatment,  both  general  and  local,  was  con- 
tinued twelve  months,  when  the  ulcer  was  completely  cicatrized. 
Four  years  elapsed  from  the  time  the  disease  was  contracted  before 
a  cure  was  effected,  which  was  much  longer  than  was  necessary  under 
a  different  treatment  to  accomplish  that  object  in  cases  equally  ag- 
gravated. 

CASE  II. — In  1854,  a  patient  was  readmitted  into  the  United 
States  Marine  Hospital  in  San  Francisco,  with  a  phagedenic  ulcer 
that  extended  from  below  the  anus  on  the  left  side,  to  the  anterior 
superior  spinous  process  of  the  ilium.  The  scrotum  was  so  exten- 
sively destroyed  that  the  testicles  were  exposed,  and  he  was  so  much 
emaciated  by  a  dysenteric  affection  that  he  was  unable  to  walk; 
which  most  probably  was  the  result  of  the  injudicious  administra- 
tion of  mercury. 

He  presented  evidences  of  having  suffered  greatly  from  its  specific 
action  on  the  mouth  and  salivary  glands.  A  pill  composed  of  aloes, 
extract  of  nux  vomica,  and  opium,  each  one  grain,  was  given  four 
times  daily,  with  a  pint  of  porter  and  nutritious  diet.  As  soon  as 
the  intestinal  irritation  subsided,  the  pills  were  discontinued  and  the 
compound  decoction  of  sarsaparilla  substituted.  When  the  general 
health  was  sufficiently  improved,  the  ulcer  was  treated  as  in  the  pre- 
ceding case,  with  the  exception  that  the  Vienna  paste  was  substi- 
tuted for  the  zinc  paste,  the  escharotic  being  allowed  to  remain  upon 
the  surface  to  which  it  was  applied  about  fifteen  minutes,  which  is 
sufficiently  long  to  produce  the  desired  effect.  Under  the  influence 
of  this  treatment  his  general  health  improved  rapidly,  and  the  ulcer 
healed  ;  he  left  the  hospital  in  good  health,  in  seven  months  from 
the  date  of  his  admission,  and  has  had  no  return  of  any  constitu- 
tional syphilitic  affection. 

This  patient  was  treated  several  months  in  the  same  institution 
by  my  predecessor,  without  obtaining  relief,  and  would  never  have 
been  cured  if  he  had  been  subjected  to  a  specific  treatment.  When- 
ever a  phagedenic  ulcer  results  from  a  bubo  that  was  treated  with 
mercurials  and  has  existed  for  a  long  period  without  being  accom- 


460  LECTURES    ON    PRACTICAL    SURGERY. 

panied  with  any  of  the  symptoms  of  either  secondary  or  tertiary 
syphilis,  mercury  should  not  be  prescribed,  as  the  specific  character 
of  the  disease  has  disappeared,  and  if  such  treatment  be  adopted,  it 
will  counteract  the  effect  of  the  general  remedies  indicated  in  such 
cases.  If  phagedenic  ulcers  in  scrofulous,  intemperate,  scorbutic,  or 
debilitated  subjects  are  treated  as  syphilitic,  although  they  were 
originally  produced  by  that  virus,  they  cannot  be  cured. 

CASE  III. — In  August,  1858,  a  patient,  aged  30  years,  and  of 
good  constitution,  who  had  been  treated  two  years  and  a  half,  visited 
San  Francisco  with  four  phagedenic  ulcers,  extending  from  the  ex- 
ternal insertion  of  Poupart's  ligament  to  the  perineum,  connected 
the  entire  distance  by  sinuses,  which  furnished  an  abundant  puru- 
lent secretion.  The  iodide  of  potassium  with  the  compound  decoc- 
tion of  sarsaparilla  were  prescribed  as  an  alterative  and  tonic,  and 
were  indicated  by  his  debilitated  condition.  MonsePs  salt  was  ap- 
plied daily  to  the  ulcers,  and  every  second  day  the  undiluted  tinc- 
ture of  iodine  was  thrown  into  the  sinuses. 

The  local  affection  disappeared  rapidly  under  this  treatment ;  his 
general  health  was  greatly  improved,  and  in  four  months  he  was  en- 
tirely relieved,  except  from  the  slight  inconvenience  produced  by  the 
occasional  appearance  of  a  small  abscess,  which  resulted  from  the 
excessively  vascular  condition  of  the  parts  originally  involved. 

CASE  IV. — In  October,  1858,  a  patient,  aged  25  years,  of  delicate 
constitution,  visited  San  Francisco  with  an  extensive  phagedenic 
ulcer  of  the  groin,  and  an  inflammatory  ulcer  involving  the  entire 
glans  penis.  One  ulcer  extended  from  the  anterior  superior  spinous 
process  of  the  ilium  to  the  pubes,  and  the  other  was  situated  upon 
the  thigh  below  Poupart's  ligament,  and  was  less  extensive.  They 
both  presented  all  the  peculiarities  of  phagedenic  ulceration,  were 
very  painful,  and  extending  rapidly.  As  this  patient  had  not  been 
subjected  to  a  specific  treatment,  the  deutochloride  of  mercury  and 
iodide  of  potassium  were  administered  in  the  combination  which  I 
have  given  you  in  a  previous  lecture.  The  compound  decoction  of 
sarsaparilla  was  administered  in  conjunction  with  the  specifics. 
Monsel's  salt  was  applied  daily,  both  to  the  chancre  and  to  the 
entire  surface  of  the  ulcers  in  the  groin.  The  former  healed  in  a 
few  days,  and  the  latter  were  completely  cicatrized  in  eight  weeks, 


LECTURE    XLV. — BUBO.  461 

which  with  the  ordinary  treatment  would  have  required  as  man} 
months. 

It  is  difficult  to  determine  the  modus  operand!  of  Monsel's  salt 
in  such  cases.  Its  action  is  certainly  both  prompt  and  extraordi- 
nary. The  surface  of  the  ulcer  soon  presents  a  more  healthy  ap- 
pearance, the  irregularity  of  the  edges  disappears  speedily.  The 
swelling  and  redness  of  the  surrounding  skin  subsides,  the  size  of 
the  ulcer  diminishes  daily,  and  when  closed  a  smooth  cicatrix  remains. 

This  local  treatment,  although  at  first  painful,  is  much  less  dis- 
tressing than  the  application  of  either  Vienna  paste  or  zinc  paste, 
nitric  acid,  or  even  nitrate  of  silver,  provided  it  be  as  long  con- 
tinued. I  have  not  found  it  necessary  to  administer  chloroform, 
which  is  indispensable  when  the  more  powerful  escharotics  are 
employed,  the  pain  resulting  from  their  application  to  an  irritable 
ulcer  being  insupportable  without  the  aid  of  anaesthetics,  the  ad- 
ministration of  which,  even  by  the  most  experienced,  is  sufficiently 
dangerous  to  render  it  necessary  to  exercise  great  caution,  even  in  sub- 
jects where  their  use  is  not  contraindicated.  Chloroform,  when  ad- 
ministered rapidly,  is  much  less  dangerous  than  when  given  slowly, 
since  then  the  quantity  absorbed  into  the  blood  not  only  protracts 
the  effect  but  increases  the  danger.  Atmospheric  air  should  be 
inhaled  freely  with  the  chloroform,  and  the  room  should  be  well 
ventilated,  so  that  the  effect  will  not  increase  after  it  is  considered 
necessary  to  withdraw  it  from  the  patient.  A  pair  of  dressing- 
forceps  should  always  be  placed  near  the  operator,  so  that  the 
tongue  may  be  drawn  forward,  and  suffocation,  when  threatened,  be 
prevented.  With  the  same  constitutional  treatment,  I  am  satisfied 
that  MonsePs  salt  will  accomplish  more  in  a  given  time  than  any 
other  escharotic  that  has  ever  been  employed. 


UY 


462          LECTURES  ON  PRACTICAL  SURGERY. 


LECTURE    XL VI. 

SECONDARY    SYPHILIS. 

GENTLEMEN  :  Before  describing  the  numerous  varieties  of  sec- 
ondary syphilis,  their  causes  and  relative  frequency  should  first  be 
determined. 

1st.  Can  secondary  symptoms  result  from  gonorrhea? 

Although  Vidal  and  other  distinguished  authors,  whose  opinions 
should  be  respected,  believe  that  cases  of  syphilitic  gonorrhoea  do  ex- 
ist, and  exercise  the  same  influence  in  producing  constitutional  symp- 
toms that  chancre  is  universally  admitted  to  exert,  still  differences 
of  opinion  exist  in  consequence  of  the  absence  of  a  sufficient  num- 
ber of  properly  authenticated  cases,  not  only  to  remove  all  doubt 
upon  the  subject,  but  also  to  render  it  even  probable  that  such  symp- 
toms ever  originate  from  that  source.  I  have  never  observed  any 
variety  of  secondary  syphilis  produced  by  an  uncomplicated  case  of 
gonorrhoea,  either  when  entirely  neglected  or  treated  with  simple 
remedies. 

That  both  chanere  and  gonorrhoea  may  be  contracted  and  exist  at 
the  same  time  in  the  urethra,  is  unquestionably  true.  With  cases 
of  this  character,  every  experienced  physician  is  familiar,  and  is  it 
not  more  rational  to  suppose  in  all  doubtful  cases,  that  both  diseases 
did  exist,  and  to  attribute  the  constitutional  affection  to  the  one  from 
which  they  are  always  expected  to  result  when  not  methodically 
treated,  rather  than  to  the  other,  from  which,  unless  more  positive 
evidence  can  be  adduced,  the  possibility  of  their  occurrence  should 
not  be  admitted  ? 

2d.  Is  the  probability  of  the  appearance  of  secondary  syphilis 
diminished  by  any  method  of  treatment  that  can  be  employed? 

So  soon  as  it  was  ascertained  that  chancre  could  be  cured  without 
mercury,  its  efficacy  for  the  eradication  of  the  poison,  and  consequently 
the  prevention  of  the  consequences,  was  also  denied.  By  many  it 
was  abandoned,  as  not  only  useless  but  highly  dangerous,  and  by 


LECTURE    XLVI. —  SECONDARY    SYPHILIS.  463 

others  because  they  believed  it  to  be  more  injurious  than  the  disease 
for  which  it  was  administered. 

Experience  has  proved  that  chancre  can  frequently  be  cured  with- 
out mercury,  and  it  has  also  been  established,  incontestably,  that 
secondary  symptoms  are  more  frequent  and  aggravated  when  it  has 
not  been  employed  in  the  treatment  of  the  primary  affection. 

Besides  the  cause  before  mentioned,  which  is  certainly  the  princi- 
pal and  most  influential,  warm  baths,  excesses,  wounds,  and  especially 
cold,  may  act  as  exciting  causes  when  the  predisposition  exists. 

If  an  opinion  were  formed  from  the  writings  of  Leonicenus,  Con- 
rad, Gilinus,  and  Torella,  no  doubt  would  be  entertained,  that  cuta- 
neous affections  were  not  only  the  most  common  variety  of  secon- 
dary disease,  but  that  pustules  were  the  characteristic  affection  of  the 
skin.  That  opinion  would  not,  however, be  sustained  by  experience, 
as  alterations  of  the  mucous  membranes  are  unquestionably  more  fre- 
quent than  are  even  diseases  of  the  skin,  which  some  writers  think 
they  resemble  so  closely  that  they  have  endeavored  to  establish  their 
identity,  and  with  some  appearance  of  success.  Baume  contends  that 
the  syphilitic  affections  of  the  buccal  mucous  membrane  present  all  the 
peculiarities  of  the  following  varieties  of  cutaneous  disease  :  Exan- 
themata, papula?,  squamae,  pustula?,  besides  several  distinct  and  more 
extensive  forms  of  ulceration.  In  his  description  of  what  he  con- 
siders different  forms  of  syphilitic  ulceration  of  the  mucous  mem- 
brane, he  certainly  exhibits  great  familiarity  with  its  specific  affec- 
tions, yet  it  must  be  admitted  that  they  neither  subserve  useful  nor 
practical  purposes,  as  it  is  always  desirable  to  simplify  a  difficult 
subject  rather  than  to  render  it  more  perplexing  and  obscure.  Two 
distinct  varieties  certainly  exist. 

First.  A  simple  erosion  of  the  buccal  mucous  membrane,  more  or 
less  red,  and  occasionally  whitish  in  the  centre.  This  frequently 
appears  upon  the  hard  and  soft  palate,  the  pharynx,  the  cheeks,  lips, 
and  tongue.  Although  they  present  a  different  appearance  in  differ- 
ent subjects,  they  agree  in  this,  that  they  are  all  superficial,  and  their 
progress  is  easily  arrested.  But  it  should  not  be  forgotten  that  they 
return  more  readily  and  frequently  than  any  other  form  of  secondary 
syphilis,  and,  notwithstanding  the  opinion  of  most  writers  to  the 
contrary,  are  the  most  difficult  to  eradicate.  In  this  form  of  ulcera- 
tion the  mucous  membrane  is  seldom  destroyed,  unless  it  be  neglected 
until  the  system  becomes  deranged  by  the  influence  of  the  poison, 


464  LECTURES    ON    PRACTICAL    SURGERY. 

and  then  it  may  assume  the  same  appearance  and  progress  with  the 
same  rapidity  as  the  following  forms  of  ulcerations  about  the  mouth. 

Second. — This  is  really  the  secondary  chancre,  and  presents  its 
peculiarities.  The  edges  are  abrupt,  indurated,  and  elevated,  and 
its  surface  is  covered  with  a  yellowish  or  grayish  membranous  secre- 
tion. It  progresses  with  great  rapidity,  and  not  only  destroys  the 
mucous  membrane,  but  also  the  subjacent  tissues.  It  frequently  fol- 
lows the  simplest  primary  affection,  and  is  so  insidious  in  its  prog- 
ress that  the  tonsils  and  soft  palate  are  destroyed  without  any 
inconvenience  being  produced  except  a  slight  difficulty  in  deglutition. 
Sometimes,  when  situated  upon  the  posterior  surface  of  the  velum 
palati,  or  the  pharynx,  the  former  is  perforated  and  the  latter  ex- 
tensively ulcerated  before  the  patient  is  aware  that  he  is  suffering 
from  anything  more  serious  than  a  simple  catarrhal  affection.  When 
located  upon  the  tongue,  they  sometimes  progress  with  so  much 
rapidity  that  they  are,  even  by  experienced  and  scientific  physicians, 
regarded  as  cancerous,  particularly  when  they  result,  as  is  not  unfre- 
quent,  from  a  very  slight  primary  affection. 

Physicians  are  often  misled  by  their  patients,  who  have  forgotten 
even  the  existence  of  a  chancre,  and  protest  against  the  possibility 
of  the  disease  resulting  from  a  specific  cause. 

In  1858,  a  patient  consulted  me  who  had  an  extensive  ulceration 
of  the  left  tonsil  and  palate,  by  which  the  former  and  nearly  half 
of  the  latter  were  destroyed,  accompanied  with  considerable  enlarge- 
ment of  the  ganglia  of  the  neck.  The  ulcer  was  regarded  as  cancer- 
ous *by  his  physicians,  and  he  appeared  to  be  so  confident,  both  of 
the  correctness  of  their  opinions  and  of  the  impossibility  of  the  ex- 
istence of  a  syphilitic  affection,  that  he  regarded  it  as  an  insult  even 
to  be  questioned  upon  the  subject,  and  would  only  consent  to  submit 
to  a  specific  treatment  when  informed  that  it  afforded  him  the  only 
chance  of  safety.  If  syphilitic,  it  could  be  cured,  but  if  cancerous, 
not  a  shadow  of  hope  remained  of  permanent  relief.  Besides  the 
extensive  and  rapidly  increasing  ulceration,  his  general  health  was 
greatly  impaired.  After  remaining  a  few  days,  he  left  San  Fran- 
cisco, as  he  supposed,  to  die  of  cancer.  In  a  few  months  I  ascer- 
tained of  a  patient  who  consulted  me  by  his  advice  that  he  was 
entirely  relieved  of  the  difficulty  from  which  he  suffered  so  much, 
both  physically  and  mentally,  and  intended,  in  a  short  time,  to  visit 
the  city  for  the  purpose  of  submitting  to  an  operation  to  remove  the 


LECTURE    XLVI.  —  SECONDARY    SYPHILIS.  465 

inconvenience  resulting  from  the  extensive  destruction  of  the  soft 
palate. 

More  recently  a  patient  visited  San  Francisco,  from  one  of  the 
cities  in  the  interior,  where  he  had  been  treated  for  an  ulcer  upon 
the  superior  and  left  side  of  the  tongue.  Having  no  interest  in 
endeavoring  to  deceive  his  physician,  he  assured  me,  when  questioned 
upon  the  subject,  that  he  had  never  had  any  form  of  venereal  disease, 
and  that  it  must  be  a  cancer,  as  his  previous  physicians  supposed. 
Believing  it  to  be  syphilitic,  I  requested  him  to  endeavor  to  recollect 
whether,  during  the  previous  year,  some  slight  ulceration  had  not 
existed  upon  the  genitals.  Upon  reflection  he  finally  arrived  at  the 
conclusion  that  a  small  ulcer  did  appear  some  months  before,  while  at 
Los  Angeles,  but  had  healed  in  a  few  days  without  treatment.  Being 
anxious  to  determine  the  true  character  of  the  difficulty,  one  of  the 
margins  of  the  ulcer  was  removed,  and  examined  microscopically  by 
my  friend,  Dr.  Trask,  of  San  Francisco,  who  pronounced  it  simple, 
being  unable  to  detect  cancer-cells  by  the  aid  of  a  powerful  in- 
strument. Antisyphilitic  treatment  was  prescribed,  and  when  he 
returned  to  San  Francisco,  a  few  weeks  subsequently,  the  ulcer  had 
entirely  healed.  This  case  is  the  more  important,  as  the  ulcer  was 
examined  by  some  of  the  most  talented  and  scientific  physicians  in 
the  State,  who,  from  its  appearance  and  history,  regarded  it  as  ma- 
lignant. If  it  had  been  a  cancer,  it  would  not  have  yielded  to  anti- 
syphilitic  treatment. 

This  form  of  syphilitic  ulceration  frequently  extends  to  the  larynx, 
destroys  the  voice,  and  by  the  contraction  resulting  from  the  cicatriza- 
tion, when  subjected  to  treatment,  the  larynx  becomes  so  constricted 
that  respiration  is  difficult  and  sometimes  almost  impossible.  A  very 
remarkable  case  of  this  kind  occurred  in  San  Francisco  in  the  spring 
of  1858.  John  Schmidt  contracted  the  disease  in  1851,  and  suffered 
from  that  time  until  the  period  before  mentioned,  successively,  with 
every  form  of  the  disease.  The  ulcers,  which  commenced  in  the 
throat,  finally  extended  into  the  larynx,  and  no  relief  was  obtained 
from  the  treatment  to  which  he  had  been  subjected.  Suffocation 
being  imminent,  I  was  requested  by  his  friends  to  visit  him,  with  the 
hope  that  temporary  relief  might  be  afforded  by  an  operation.  His 
breathing  was  so  difficult  that  each  inspiration  could  be  heard  in  any 
of  the  adjoining  houses.  The  skin  and  cellular  tissue  upon  the 
anterior  part  of  the  neck  were  excessively  thickened  by  the  long-con- 


466  LECTURES    ON    PRACTICAL    SURGERY. 

tinned  use  of  both  rubefacients  and  blisters.  Believing  that  his  life 
could  only  be  prolonged  by  an  operation,  laryngotomy  was  performed 
immediately,  and  a  tube  introduced.  The  haemorrhage,  both  during 
and  for  a  few  hours  subsequent  to  the  operation  was  inconsiderable ; 
but  in  the  evening,  upon  removing  the  tube  to  clear  it  of  the  mucus 
by  which  it  was  obstructed,  bleeding  became  so  profuse  as  to  endan- 
ger life.  Finding  it  impossible,  without  enlarging  the  wound,  to 
ligate  the  vessels,  Monsel's  salt  was  applied,  and,  by  its  extraordi- 
nary hsemostatic  properties,  I  was  relieved  from  an  exceedingly 
unpleasant  position.  The  ordinary  tracheal  tube,  goose-quills,  or 
the  section  of  a  gum-elastic  catheter  have  now  been  worn  for  several 
years.  Proper  treatment  was  substituted  for  that  previously  pre- 
scribed, his  general  health  improved  greatly,  the  specific  action  was 
controlled,  and  its  entire  eradication  was  probably  effected.  When 
conversing,  he  placed  his  finger  upon  the  extremity  of  the  tube;  its 
presence  produced  but  little  irritation  or  inconvenience;  the  embar- 
rassment of  the  lungs  resulting  from  the  long-continued  and  exces- 
sive efforts  required  for  respiration  entirely  disappeared,  and  he 
became  quite  comfortable,  notwithstanding  he  has  been  preserved 
from  suffocation  by  artificial  means  for  a  longer  period  than  any 
other  patient  whose  case  has  been  recorded. 

Secondary  ulceration  is  not  confined  to  the  buccal  mucous  mem- 
brane, but  frequently  either  extends  to  the  mucous  membrane  of  the 
nose,  or  is  developed  there  before  the  mouth  or  throat  becomes 
affected.  At  first  a  simple  irritation  exists,  which  may  be  mistaken 
for  an  ordinary  catarrhal  affection,  and  gradually  increases  until  the 
mucous  membrane  becomes  ulcerated,  accompanied  with  a  thick, 
yellow  purulent  discharge.  When  entirely  destroyed,  the  bones  are 
exposed,  become  denuded,  and  ultimately  carious,  and  when  de- 
tached may  escape  anteriorly,  or  through  the  soft  palate,  which  fre- 
quently ulcerates  in  consequence  of  the  irritation  produced  by  the 
diseased  palate-bones  resting  upon  its  superior  surface.  So  soon  as 
the  vitality  of  the  bones  is  destroyed,  the  discharge  becomes  profuse, 
and  is  accompanied  with  an  excessively  offensive  odor. 

Caries  of  the  small  bones  of  the  nose  may  result  either  from  second- 
ary or  tertiary  syphilis.  In  the  former  the  disease  commences  in  the 
mucous  membrane,  and  in  the  latter  the  periosteum  is  primarily 
affected. 

The  most  remarkable  case  of  caries  of  the  nasal  bones  resulting 


LECTURE    XLVI.  —  SECONDARY    SYPHILIS.  467 

from  secondary  syphilis  which  I  have  either  seen  or  treated,  occurred 
in  1857.  A  gentleman  of  good  constitution,  and  in  fine  health,  con- 
tracted syphilis  in  San  Francisco,  and  was  treated  as  such  cases  too 
frequently  are  in  this  city.  In  a  few  weeks,  secondary  ulceration  of 
the  skin  and  irritation  of  the  mucous  membrane  of  the  nose  super- 
vened. Although  several  months  elapsed  before  he  became  my 
patient,  all  the  bones  of  the  palate  and  nose  were  diseased,  and  an 
opening  an  inch  in  diameter  existed  between  the  mouth  and  the 
nasal  cavities.  The  purulent  discharge  was  profuse  and  intolerably 
offensive.  An  ulcer  extended  from  the  superciliary  ridges  to  the 
posterior  parts  of  the  parietal  bones.  His  general  health  was  greatly 
impaired,  and  his  condition  as  unfavorable  as  can  possibly  be  im- 
agined. The  deutochloride  of  mercury,  combined  with  the  iodide 
of  potassium,  and  the  compound  decoction  of  sarsaparilla,  together 
with  porter  and  a  generous  diet,  were  prescribed.  His  general  health 
improved  daily,  the  external  ulcer  healed,  and  in  three  months  his 
weight  increased  fifty-six  pounds.  The  diseased  bones  being  mov- 
able, they  were  all  extracted  through  the  opening  in  the  soft  palate, 
which  being  accomplished,  the  fetor  disappeared,  and  as  no  symp- 
toms of  disease  existed,  the  treatment  was  discontinued.  Neither 
the  nasal  bones  nor  those  by  which  they  are  supported  being  impli- 
cated, the  nose  has  retained  its  original  conformation.  The  opening 
in  the  palate  has  been  covered  so  perfectly  by  a  dentist  that  his  voice 
is  restored,  and  but  little  evidence  remains  of  the  extensive  ravages 
committed  by  this  fearful  disease  in  so  short  a  period. 

In  many  cases  the  mucous  membrane  covering  the  septum  and  the 
cartilage  is  destroyed,  by  which  the  nasal  passages  are  converted 
into  a  common  cavity.  So  little  inconvenience  frequently  results 
from  this  difficulty  that  the  patient  is  ignorant  of  the  existence  of 
anything  more  than  irritation  of  the  membrane  until  the  destruction 
of  the  cartilage  is  complete,  by  which  the  nose  is  flattened,  and  an 
exceedingly  unpleasant  deformity  produced,  which  cannot  be  re- 
moved. 

By  extensive  ulceration  of  the  throat  the  Eustachian  tubes  are 
frequently  implicated,  from  which  partial  deafness  may  result.  The 
meatus  auditorius  externus  is  also  occasionally  affected,  and  very 
troublesome  vegetations  close  the  canal,  and  as  long  as  they  remain 
the  function  of  the  organ  is  destroyed. 

When  other  varieties  of  secondary  syphilis  exist,  the  mucous  mem- 


468  LECTURES    ON    PRACTICAL    SURGERY. 

brane  of  the  vagina,  glans  penis,  and  urethra  sometimes  becomes 
inflamed,  and  is  accompanied  with  a  very  unpleasant  discharge, 
which,  I  am  confident,  is  often  mistaken  for  primary  syphilitic 
gonorrhoea,  from  which,  as  many  suppose,  constitutional  symptoms 
result. 

When  neglected,  ulceration  of  the  mucous  membrane,  both  of  the 
vagina  and  uterus,  frequently  occurs,  which  can  only  be  removed  by 
a  specific  treatment. 

In  the  consideration  of  secondary  ulceration  of  the  mucous  mem- 
brane, the  question  necessarily  arises,  is  the  discharge  in  that  stage 
communicable,  either  by  contact  or  otherwise?  Vidal  says  that 
secondary  syphilis  is  inoculable,  and  experience  has  convinced  me 
that  in  cases  where  there  was  no  probability  of  the  disease  being 
contracted  from  a  primary  ulcer,  it  did  exist,  and  presented  all  the 
peculiarities  of  a  primary  affection. 

In  one  of  the  cases  referred  to,  a  gentleman  was  married  when 
suffering  from  secondary  ulceration  of  the  mucous  membrane  of  the 
lips  and  throat.  In  a  few  weeks  a  chancre  appeared  upon  his  wife's 
left  nipple,  which  yielded  to  the  ordinary  treatment,  but  the  lady, 
being  ignorant  of  the  character  of  the  disease,  could  not  be  induced 
to  continue  the  treatment  sufficiently  long  to  eradicate  the  virus. 
In  six  weeks  she  had  the  same  affection  of  the  mucous  membrane  of 
the  mouth  that  existed  in  her  husband's  case,  and  it  was  soon  fol- 
lowed by  a  syphilitic  cutaneous  eruption. 

Syphilis  is  also  hereditary,  and  may  be  communicated  either  by 
the  father  or  mother.  Vidal  thinks  that  the  virus  exists  in  the 
blood,  and  consequently  that  semen  secreted  from  impure  blood 
possesses  the  same  qualities.  If  a  pregnant  woman  be  affected  with 
secondary  syphilis,  the  child  is  frequently  expelled  prematurely,  and 
is  covered  with  syphilitic  ulcers,  by  which  the  process  of  gestation 
is  interrupted. 

Treatment. — Although,  as  I  before  said  to  you,  superficial  ulcera- 
tions  of  the  mucous  membrane  of  the  tongue,  mouth,  or  throat,  are 
generally  regarded  as  very  simple  and  easily  cured,  I  have  always 
found  them  less  amenable  to  treatment  than  cases  of  a  much  more 
serious  character.  In  consequence  of  their  uniform  obstinacy,  I  have 
tested  the  relative  efficacy  of  the  various  remedies  that  have  been 
recommended,  and  have  found  no  difference  in  the  action  of  the  prot- 
iodide  of  mercury  and  blue  mass.  They  should  be  administered 


LECTURE    XLVI. — SECONDARY    SYPHILIS.  469 

in  the  manner  that  I  described  in  a  previous  lecture,  and  continued 
much  longer  than  in  any  other  secondary  affection,  in  order  to  pre- 
vent a  recurrence,  as  relapses  are  more  common  in  this  than  in  any 
of  the  more  aggravated  forms  of  the  disease.  In  combination  with 
the  mercurial  treatment,  the  compound  decoction  of  sarsaparilla 
is  exceedingly  valuable,  particularly  when  the  general  health  is 
impaired.  It  is  both  a  tonic  and  an  alterative,  and  thereby  in- 
creases the  tolerance  of  the  system  to  the  mercurials  that  may  be 
found  necessary. 

In  the  more  destructive  forms  of  ulceration  of  the  mucous  mem- 
brane of  the  mouth  and  nose,  the  iodide  of  potassium  is  relied 
upon  almost  exclusively  by  many  celebrated  physicians,  which  to 
me  is  very  surprising,  as  I  have  long  been  convinced  by  experi- 
ence that  in  syphilis  it  is  not  a  curative  remedy.  Ulcerations 
of  the  mucous  membrane  will  disappear  during  its  administration, 
but  very  soon  after  it  has  been  discontinued  they  invariably  return  ; 
not  a  single  exception  has  been  observed,  where  the  condition  of  a 
patient  treated  with  this  article  alone  could  be  possibly  ascertained 
after  a  sufficient  time  had  elapsed  for  the  disease  to  reappear. 

In  those  cases  which  frequently  progress  with  so  much  rapidity 
as  to  endanger  the  tissues  upon  which  the  mucous  membrane  is  lo- 
cated, the  iodide  of  potassium  should  be  combined  with  a  mercurial, 
and  given  as  freely  as  can  be  tolerated ;  eight  grains  of  the  salt 
combined  with  deutochloride  of  mercury  is  certainly  the  best  prepa- 
ration that  can  be  administered.  When  taken  even  in  that  quantity, 
it  frequently  produces  very  unpleasant  symptoms,  such  as  distress- 
ing pain  through  the  anterior  part  of  the  head,  as  well  as  inflamma- 
tion of  the  mucous  membrane  of  the  eyes,  nose,  and  mouth,  accom- 
panied with  a  profuse  discharge  of  mucus  and  saliva.  When  these 
effects  are  produced,  it  should  be  discontinued  until  they  disappear, 
when  it  may  be  resumed  in  similar  doses.  Should  a  tonic  be  neces- 
sary, none  will  be  found  more  useful  than  the  decoction  of  sarsapa- 
rilla which  I  have  before  recommended. 

Local  Treatment. — A  solution  of  the  iodide  of  potassium  in  water, 
one  part  of  the  former  to  ten  parts  of  the  latter,  is  highly  recom- 
mended as  a  local  application,  which  should  be  either  applied  with 
a  brush  or  used  as  a  gargle,  as  may  be  most  convenient. 

Van   Swieten's  liquor,  in  eight  parts  of  water  and  double  the 


470          LECTURES  ON  PRACTICAL  SURGERY. 

quantity  of  honey,  is  highly  recommended  by  Vidal,  and  is,  in 
many  cases,  very  valuable. 

One  part  of  muriatic  acid  diluted  with  two  parts  of  water,  is  a 
very  efficacious  local  remedy,  and  when  more  simple  means  fail,  it 
should  be  employed.  A  physician  in  this  city  has  great  confidence 
in  a  solution  composed  of  twenty  grains  of  the  deutochloride  of  mer- 
cury, twenty  grains  of  the  muriate  of  ammonia,  and  one  ounce  of 
water ;  this  solution  should  be  applied  daily  with  a  brush,  and  con- 
tinued until  the  ulcers  disappear. 

The  solid  nitrate  of  silver,  either  in  simple  or  irritable  and  pain- 
ful ulcers  of  the  mucous  membrane,  when  not  progressing  with 
great  rapidity,  is  equally  as  efficacious  and  much  more  convenient 
than  any  other  local  remedy;  although  when  they  are  extending 
rapidly,  pure  nitric  acid  should  be  applied.  This  may  not  be  su- 
perior to  the  muriatic  acid,  yet  having  often  arrested  phagedenic 
ulcers,  both  in  the  mouth  and  upon  other  portions  of  the  body,  with 
nitric  acid,  I  rely  more  confidently  upon  its  action  than  upon  any 
other  article  with  which  I  am  less  familiar. 


LECTURE    XLVII.  —  SECONDARY    SYPHILIS.  471 


LECTURE 


SECONDARY   SYPHILIS. 

GENTLEMEN  :  Before  the  syphilitic  affections  of  the  skin  are  con- 
sidered, it  becomes  again  necessary  that  I  should  direct  your  attention 
especially  to  a  very  common  secondary  affection  of  the  throat,  con- 
junctiva, prepuce,  and  vagina,  of  an  exanthematous  character,  which 
in  my  last  lecture  did  not  receive  the  attention  necessary  to  convey 
a  correct  knowledge  of  its  character.  This  is  not  only  a  very  com- 
mon difficulty,  but  also  a  very  hard  one  to  recognize,  without  the 
existence  of  other  symptoms.  Chronic  exanthematous  inflammation 
of  the  mucous  membrane  of  the  tonsils,  palate,  and  pharynx  is  often 
mistaken  for  either  a  scrofulous  or  catarrhal  affection,  and  only  at- 
tracts attention  by  its  great  obstinacy.  Although  it  is  not  accompa- 
nied with  ulceration,  deglutition  is  both  painful  and  difficult.  The 
mucous  membrane  is  red,  thickened,  and  there  is  generally  also 
enlargement  of  the  tonsils  and  submaxillary  glands.  The  mucous 
membrane  of  the  vagina  and  prepuce  presents  the  same  appearance, 
and  furnishes  a  morbid  secretion,  from  which,  as  I  before  stated,  the 
secondary  symptoms  most  probably  result  that  have  been  attributed 
to  gonorrhoea. 

Syphilides. — The  profession  is  indebted  for  this  very  convenient 
and  expressive  word  to  Alibert,  one  of  the  most  distinguished  phy- 
sicians of  the  St.  Louis  Hospital,  in  Paris.  It  has  effectually  re- 
moved the  error  and  confusion  necessarily  resulting  from  the  em- 
ployment of  the  term  pustule  to  designate  all  cutaneous  syphilitic 
affections.  To  Biett,  who  was  equally  eminent,  and  who  labored  in 
the  same  hospital,  we  should  feel  under  greater  obligations  for  having 
classified  and  arranged  them  according  to  the  method  adopted  by 
Willan  in  his  treatise  on  the  elementary  affections  of  the  skin,  which 
has  removed  much  of  the  obscurity  and  difficulty  previously  expe- 
rienced in  the  study  of  the  diseases  of  this  tissue. 

A  familiarity  with  the  syphilides  is  of  great  importance  to  the 


472  LECTURES    ON    PRACTICAL    SURGERY. 

physician,  for  without  that  knowledge,  from  their  resemblance  to  the 
simple  affections  that  present  the  same  appearance,  an  inefficient 
treatment  might  be  prescribed  and  continued  till  the  system  became 
so  much  deranged  by  the  virus  that  it  would  not  only  be  difficult, 
but  often  impossible  to  arrest  their  progress. 

They  differ  from  simple  cutaneous  affections  in  color  and  form, 
and  leave  a  different  impression  upon  the  skin  when  they  cicatrize. 
In  forming  a  diagnosis  the  color,  both  of  the  eruption  and  of  the  ad- 
jacent skin,  is  considered  of  the  greatest  consequence.  They  gener- 
ally present  shades  differing  from  a  purplish-red  to  an  earthy-yellow, 
which  is  usually  termed  coppery.  This  peculiarity  of  color  is  suffi- 
ciently distinct  to  remove  all  doubt  respecting  their  true  character, 
except  for  a  few  days  after  the  exanthemata  make  their  appearance, 
which  so  nearly  resemble  roseola,  that  if  other  circumstances  were  not 
considered  an  error  might  be  committed.  When  doubt  exists,  if  the 
red  color  be  removed  by  pressure,  the  coppery  appearance  is  rendered 
more  distinct.  It  remains  because  it  has  been  produced  by  a  pig- 
ment that  has  been  deposited  in  the  skin,  and  which  is  consequently 
more  permanent  than  that  produced  by  mere  vascular  engorgement 
of  the  part. 

Form  stands  next  to  color  in  importance.  Syphilides  usually,  and 
those  of  long  standing  almost  invariably,  present  curves  which  rep- 
resent portions  of  a  circle.  This  peculiarity  has  long  attracted  the 
attention  of  physicians,  and  accounts  for  the  origin  of  the  term,  "co- 
rona veneris." 

Cicatrix. — It  is  well  known  that  ulcers  are  more  common  in  the 
syphilitic  than  in  the  elementary  diseases  of  the  skin,  and  that  they 
present  a  different  appearance.  Their  edges  are  abrupt,  elevated, 
and  frequently  indurated,  and  the  surface  is  covered  with  a  gray- 
ish secretion,  which  is  detached  with  great  difficulty.  This  pecu- 
liarity is  particularly  observed  upon  the  extremities,  although  it  is 
apparent  wherever  the  ulcers  are  located.  In  consequence  of  the 
form,  depth,  and  irregularity  of  these  ulcers,  the  cicatrix  presents  a 
different  appearance  from  that  usually  resulting  from  simple  cuta- 
neous affections. 

Although  an  experienced  physician,  who  is  familiar  with  the  pecu- 
liarities which  I  have  just  described,  seldom  experiences  the  slightest 
difficulty  in  recognizing  even  the  more  complicated  syphilitic  erup- 
tions, he  should  always  obtain  the  history  of  the  case,  and  observe 


LECTURE    XLVII.  —  SECONDARY    SYPHILIS.  473 

the  constitutional  condition  that  may  exist,  before  determining  upon 
a  course  of  treatment. 

Incubation. — The  time  that  elapses  between  the  date  of  the  affec- 
tion and  the  appearance  of  the  disease  has  received  this  appellation. 

This  period  varies  from  six  weeks  to  several  months,  and  accord- 
ing to  the  latest  writers  upon  the  subject  may  extend  even  to  many 
years.  It  is  generally  believed  that  they  formerly  appeared  much 
sooner  than  at  present,  and  exhibited  greater  uniformity  in  their 
character.  Before  syphilitic  eruptions  appear,  febrile  symptoms 
often  exist  for  several  days,  and  frequently  continue  during  the  acute 
stage ;  this  is  particularly  the  case  in  subjects  constitutionally  feeble, 
or  who  have  been  rendered  so  by  previous  disease,  which  makes  the 
treatment  more  difficult,  and  the  effects  of  remedies  more  uncertain 
if  prescribed  during  their  continuance. 

Thirty  years  ago  Lagneau,  who  was  regarded  as  one  of  the  ablest 
writers  upon  the  subject,  considered  all  syphilitic  eruptions  pustu- 
lar, and  described  them  as  miliary,  urticose,  lenticular,  formicular, 
psoriasic,  herpetic,  crustaceous,  and  ulcerous  pustules,  which  is  much 
less  simple  and  satisfactory  than  the  arrangement  adopted  by  Biett 
and  his  students,  and  previously  pursued  by  Willan  in  his  treatise 
on  the  elementary  diseases  of  the  skin,  a  correct  knowledge  of  which 
is  indispensable  to  the  study  of  the  syphilides.  The  varieties  that 
are  admitted  and  established  will  only  be  given  : 

1st.  Exanthemata. 
2d.  Papulse. 
3d.  Squamse. 
4th.  Vesiculse. 
5th.  Bulte. 
6th.  Pustulse. 
7th.  Tuberculse. 

To  which  may  be  added  onychia  and  alopecia. 

1st.  Syphilitic  Exanthema. — This  appears  in  irregular  red  spots,, 
separated  by  healthy  portions  of  skin,  and  in  consequence  of  the 
striking  resemblance  that  exists  to  roseola  vulgaris,  they  naturally 
belong  to  the  same  class.  Although  the  skin  is  red,  and  presents  a 
rough  appearance  to  the  touch,  it  is  not  distinctly  elevated.  This 
eruption  frequently  appears  suddenly,  and  is  seldom  accompanied 
with  much  fever  or  distressing  pruritus;  after  it  has  existed  a 


474  LECTURES    ON    PRACTICAL    SURGERY. 

few  days,  the  coppery  color  peculiar  to  all  the  syphilides  becomes  very 
distinct.  In  consequence  of  the  absence  of  fever,  the  persistence  of 
the  eruption,  and  the  color  it  assumes,  it  cannot  be  mistaken  for 
roseola  vulgaris,  the  only  disease  to  which  it  bears  a  strong  resem- 
blance. This  is  one  of  the  most  simple,  most  readily  diagnosed,  and 
most  manageable  of  all  the  syphilitic  eruptions. 

2d.  Syphilitic  Papulae. — In  this  form  of  the  disease  small,  dry, 
and  firm  elevations  appear,  of  a  decided  copper  color,  which  do  not 
contain  any  fluid,  and  which  terminate  either  by  resolution  or  des- 
quamation.  They  present  no  regularity  in  their  arrangement,  are 
generally  more  numerous  upon  the  anterior  portions  of  the  lower 
extremities,  and  are  frequently  preceded  by  syphilitic  rheumatism  or 
by  inflammation  of  the  iris  or  conjunctiva. 

I  was  consulted,  some  time  since,  by  a  man  who  was  suifering 
from  conjunctivitis,  and  as  he  complained  of  pains  in  the  lower  ex- 
tremities, they  were  examined,  and  were  found  to  be  covered  with 
papulae  of  the  variety  termed  lichen ;  the  tumors  were  very  small, 
although  numerous,  of  a  yellow  color,  and  in  a  state  of  desquarna- 
tion.  He  had  been  treated  for  a  chancre  a  few  weeks  previously, 
but  had  discontinued  the  treatment  before  the  disease  was  eradicated. 

Occasionally  the  papulae  are  much  larger,  distinct,  and  copper- 
colored  ;  they  always  progress  slowly,  and  generally  terminate  by 
resolution.  This  affection  was  formerly  described  as  syphilitic  urti- 
caria, from  the  strong  resemblance  which  it  presents  to  that  affection 
both  in  its  appearance  and  termination.  Iritis  is  one  of  its  most 
common  complications. 

3.  Syphilitic  Squamce. — This  variety  of  secondary  cutaneous  dis- 
ease, as  its  name  indicates,  presents  a  scaly  appearance,  which  re- 
sults from  the  desquamation  of  the  cuticle.  The  pimples  are  more 
or  less  elevated,  of  a  dull-red  or  copper  color,  and  are  frequently  ob- 
served after  an  erythematous  or  vesicular  eruption  has  disappeared. 
When  primitive,  they  frequently  assume  the  form  of  the  common 
varieties  of  psoriasis,  and  may  exist  either  in  distinct  blotches  or 
circles.  The  former  may  either  be  separated  by  healthy  portions  of 
skin,  or  so  numerous  that  their  margins  are  in  contact.  They  vary 
in  size  from  a  bean  to  a  twenty-five  cent  piece,  and  resemble  the 
eruption  in  psoriasis  only  in  form  and  size.  When  the  summit 
ulcerates,  and  the  secretion  escapes  and  desiccates,  they  generally 
present  a  scaly  appearance,  although  occasionally  they  are  smooth 


LECTURE    XLVII.  —  SECONDARY    SYPHILIS.  475 

and  polished.    The  surface,  after  the  scabs  are  detached,  is  generally 
smooth  and  of  a  dark  or  livid  color. 

Circular  Psoriasis  or  Syphilitic  Leprosy. — The  circles  repre- 
sented by  this  eruption  vary  in  size  from  two  or  three  lines  to  half 
an  inch  in  diameter,  and  are  generally  dark-brown,  violet,  or  black- 
ish in  the  centre,  and  frequently  enlarge  by  healing  in  the  centre 
and  extending  at  the  margins.  These  rings  are  composed  of  pim- 
ples, which  present  a  red  base  and  a  summit  filled  with  yellow  pus. 
They  are  most  frequently  located  upon  the  forehead,  and  constitute 
what  was  originally  called  the  crown  of  Venus.  When  this  erup- 
tion appears  upon  the  palms  of  the  hands  and  soles  of  the  feet,  the 
scales  are  thicker,  more  firm  and  horny,  resulting  from  the  character 
of  the  epidermis  by  which  they  are  covered,  which  is  both  thickened 
and  indurated,  and  consequently  deprived  of  its  elasticity.  The  mo- 
tion of  the  fingers  is  not  only  impaired,  but  large  fissures  are  also 
formed,  that  are  both  painful  and  exceedingly  obstinate.  The  erup- 
tion might  be  confounded  with  psoriasis  vulgaris,  from  which,  how- 
ever, it  differs  by  the  almost  entire  absence  of  pruritus,  as  well  as 
by  the  presence  of  the  copper  color  of  the  skin  surrounding  the  erup- 
tion. This  form  of  secondary  syphilis  was  formerly  described  as 
pustular  psoriasis. 

4.  Syphilitic  Vesiculce. — "When  the  cuticle  is  elevated  by  a  serous 
or  sero-purulent  secretion,  a  vesicle  is  produced.     This  variety  in- 
cludes all  the  syphilitic  eruptions  characterized  by  vesicles,  which 
may  be  designated  syphilitic  eczema,  syphilitic  herpes,  and  syphilitic 
varicella.    In  this  form  of  the  disease  the  vesicles  are  generally  small, 
transparent,  and  sometimes  pearly  white.     When  punctured,  they 
frequently  refill,  but  occasionally  the  summit  becomes  dry,  and  is 
covered  with  a  yellow  scab  or  thin  scale.     In  other  cases  the  erup- 
tion consists  of  a  dark-red  blotch,  covered  with  prominent  vesicles, 
which  are  firm,  remain  stationary,  and  finally  disappear,  leaving  the 
affected  part  of  a  copper  color,  either  smooth  or  covered  with  a  slight 
desquamation.     This   is    the   most   common    variety   of  syphilitic 
eczema. 

5.  Herpes  Syphilitica. — In  this  affection  the  vesicles  are  generally 
arranged  in  circles,  and  vary  from  three  lines  to  an  inch  in  diameter. 
The  number  of  these  circles  is  very  limited,  and  cannot  easily  be 
mistaken  for  herpes  simplex,  in  consequence  of  the  distinct  yellow- 
ness of  the  skin  surrounding  the  base.     When  this  variety  appears 


476          LECTURES  ON  PRACTICAL  SURGERY. 

near  the  anus,  it  receives  the  name  of  prurigo  podicis,  and  is  one  of 
the  most  distressing  and  troublesome  of  the  venereal  affections.  It 
frequently  extends  to  the  scrotum  and  upper  part  of  the  thigh,  and 
is  accompanied  with  excessive  itching,  especially  at  night.  It  is  of 
a  brownish  copper-color,  and  sometimes  becomes  ulcerated  and  cov- 
ered with  a  whitish  secretion  similar  to  that  observed  in  the  throat. 

Women  are  affected  with  the  same  variety  of  syphilitic  herpes, 
which  is  known  as  prurigo  pudendi,  and  appears  upon  the  labia,  or- 
ifice of  the  vagina,  and  upper  part  of  the  thighs,  and  is  attended  with 
excessive  pruritus.  The  eruption  is  first  characterized  by  small  deep- 
red  pimples  distributed  over  the  parts  just  mentioned.  When 
chronic,  the  skin  presents  a  yellowish-brown  or  uniform  livid  tint. 
This  affection  should  not  be  confounded  with  the  pruritus  that  af- 
fects pregnant  women  or  those  in  whom  the  menstrual  discharge  is 
suppressed. 

I  treated,  in  1858,  an  extraordinary  and  distressing  case  of  prurigo 
pudendi,  in  a  patient  from  the  interior  of  the  State,  in  which  the 
labia  were  enormously  enlarged,  and  the  mucous  membrane  and  skin 
at  the  orifice  of  the  vagina,  and  upon  the  thighs,  was  thickened  and 
covered  with  a  thin,  irritating,  and  offensive  discharge.  The  pruri- 
tus in  this  case  was  intolerable,  and  the  excessive  swelling  of  the 
labia  was  probably  produced  by  the  violence  resulting  from  the  means 
resorted  to  for  the  purpose  of  obtaining  temporary  relief.  Exten- 
sive ulceration  of  the  rectum  with  contraction  also  existed. 

4.  Syphilitic  Varicella. — This  is  much  more  common  than  either 
of  the  other  varieties.     The  vesicles  are  scattered  irregularly  over 
the  body,  and  are  either  globular,  acuminated,  or  umbilicated.  ,  The 
serum  which  they  contain  frequently  becomes  turbid  and  purulent, 
and  then  they  resemble  varioloid  more  than  varicella,  from  which 
they  can  be  distinguished  by  the  color  which  they  present,  which 
is  peculiar  to  every  variety  of  secondary  eruption,  and  is  so  distinct 
that  it  cannot  be  mistaken  by  an  experienced  physician,  even  upon 
the  most  superficial  examination. 

5.  Syphilitic  Bullce. — This  affection  rarely  occurs  in   the   adult. 
The  vesicles  are  much  larger  than  in  the  preceding  variety,  although 
not  more  elevated.     In  magnitude  they  vary  from  the  size  of  a  pea 
to  that  of  a  goose-egg.     Two  distinct  varieties  have  been  observed. 
After  maturity,  when  the  vesicles  are  covered  with  scabs,  it  is  called 
pemphigus,  and  rupia  when  a  thick  scale  or  crust  is  formed. 


LECTURE    XLVII.  —  SECONDARY    SYPHILIS.  477 

Syphilitic-  Pemphigus. — The  vesicles,  as  they  may  be  called,  although 
sometimes  filled  with  a  sero-purulent  fluid,  in  this  variety  of  bullas, 
rarely  exceed  in  dimensions  a  twenty-five  cent  piece,  are  surrounded 
by  a  red  areola  until  they  open,  and  then  they  are  covered  with 
scales,  and  around  the  base  the  copper  color  is  distinct.  This  variety 
of  the  disease  is  common  in  young  children  soon  after  birth,  and  is 
frequently  complicated  with  disease  of  the  lungs,  which  generally 
proves  fatal. 

Syphilitic  Rupia. — This  is  more  common  than  pemphigus,  and  is 
characterized  by  large  bullse,  which  are  flat,  generally  round,  and  are 
surrounded  by  a  copper-colored  areola.  They  contain  a  blackish 
fluid,  which,  when  it  escapes,  speedily  desiccates.  This  eruption 
may  appear  upon  every  portion  of  the  body,  although  it  is  most 
common  upon  the  forehead  and  scalp.  Generally  the  number  is 
limited  to  two  or  three,  and  these,  when  upon  the  extremities,  are 
usually  very  large.  When  the  ulcerated  surface  is  extensive,  an 
enormous  black  or  brown  conical  scab  is  formed,  which,  if  not  de- 
tached, either  by  violence  or  by  some  oleaginous  application,  fre- 
quently becomes  more  than  an  inch  in  length. 

A  very  distinctly  marked  case  of  syphilitic  rupia  was  treated  in 
the  United  States  Marine  Hospital,  in  1857.  The  patient  was 
young  and  large,  although  of  a  scrofulous  habit,  there  being  several 
cicatrices  on  the  neck  resulting  from  that  disease.  The  primary 
disease  was  treated  by  the  usual  remedies,  but  before  the  chancre 
healed,  he  lost  his  appetite,  fever  supervened,  and  continued  until 
the  bullae  made  their  appearance.  Besides  several  of  large  size 
upon  the  body,  two  appeared  upon  the  forehead,  which  contained 
a  dark-colored  fluid,  and  by  its  escape  and  desiccation  black  scabs 
more  than  an  inch  in  length  were  produced.  Great  prostration, 
with  syphilitic  rheumatism,  invariably  followed  the  use  of  mercury, 
even  in  the  smallest  doses,  and  when  combined  with  iodide  of 
potassium,  which  rendered  it  necessary  to  suspend  its  administration 
frequently  for  more  than  a  week  during  the  treatment.  Although 
this  case  was  for  several  months  very  unpromising,  by  generous 
diet,  the  mixture  which  has  been  before  described,  the  compound 
decoction  of  sarsaparilla,  and  the  free  use  of  porter,  the  ulcers  finally 
healed,  but  were  followed  by  tertiary  symptoms,  which  rendered  a 
continuance  of  the  treatment  for  several  months  indispensably  neces- 
sary. 


478  LECTURES    ON    PRACTICAL    SURGERY. 

A  deep,  irregular,  and  extensive  cicatrix  now  represents  the  site 
of  each  of  the  ulcers,  which  will  never  disappear,  although  he  has, 
for  several  years,  enjoyed  uninterrupted  health.  This  form  of  dis- 
ease becomes  serious  in  proportion  to  the  constitutional  debility  that 
may  exist.  It  generally  progresses  slowly,  and  is  as  obstinate  as 
any  other  form  of  secondary  syphilis. 

6.  Syphilitic  Pustulce. — A  small  tumor  produced  by  the  eleva- 
tion of  the  cuticle  by  a  purulent  secretion  is  called  a  pustule.  This 
syphilitic  eruption  was  more  common  about  the  end  of  the  fifteenth 
century  than  at  present,  and  was  described  as  lenticular,  from  the 
resemblance  of  the  pustules,  both  in  size  and  shape,  to  the  vegetable 
product,  a  sort  of  bean,  from  which  they  derived  their  name.  Two 
distinct  varieties  have  been  observed,  syphilitic  impetigo  and  syphi- 
litic ecthyma. 

The  former  may  be  either  distinct  or  confluent.  The  pustules  in 
the  simple  or  distinct  form  are  but  slightly  elevated,  and  generally 
are  not  very  numerous.  The  base  is  not  indurated,  and  presents  a 
copper  color.  When  neglected,  scales  are  formed  from  the  exfolia- 
tion of  the  cuticle,  and  occasionally  small  scabs  appear,  by  which 
an  ulcer  is  concealed,  that  usually  leaves  a  firm  and  permanent 
cicatrix. 

The  confluent  form  is  frequently  preceded  by  lassitude  and  fever. 
The  skin  presents  a  red  color  before  the  appearance  of  the  pustules, 
which  are  so  numerous  as  to  become  confounded,  and  are  soon 
covered  with  a  soft,  unequal,  or  greenish  scab,  which  is  convex  in 
the  centre,  leaving,  when  detached,  an  irregular  ulcer  with  abrupt 
edges. 

Syphilitic  Ecthyma. — In  ecthyma  syphilitica  the  pustules  are 
larger  than  in  impetigo,  although  they  rarely  exceed  an  inch  in 
diameter.  They  are  rapidly  developed,  soon  mature,  and  become 
covered  with  a  thick  scab.  These  are  frequently  so  large  as  to  be 
mistaken  for  rupia,  from  which  they  can  easily  be  distinguished,  if 
seen  before  the  pustules  mature.  They  frequently  appear  upon  the 
lips  and  alse  of  the  nose,  and  are  both  obstinate  and  destructive. 

In  July,  1874,  at  the  County  Hospital,  I  found  a  man  in  my 
ward  who  had  a  syphilitic  ulcer  which  involved  the  entire  upper 
lip,  and  extended  on  the  left  side  below  the  lower  edge  of  the  in- 
ferior maxillary  bone.  His  palate  was  destroyed,  his  nose  dis- 
figured, and  altogether  his  condition  was  anything  but  encouraging. 


LECTURE    XLVII.  —  SECONDARY    SYPHILIS. 


479 


I  put  him  under  the  antisyphilitic  treatment  which  is 
scribed  in  my  wards  in  the  County  Hospital.  In  a  week 
had  improved  so  much  that  I  decided  to  remove  the 
transplant  enough  healthy  skin  from  the  side  of  the  face 
the  deficiency.  Although  he  had  erysipelas,  the  wound 


now  pre- 
or  two  he 
ulcer  and 
to  supply 
healed  by 


the  first  intention,  and  now  his  is  one  of  the  most  successful  opera- 
tions that  has  ever  been  performed  in  this  or  any  other  State.  It 
was  witnessed  by  the  entire  class  of  the  Medical  Department  of  the 
University  of  California.  He  is  now  in  good  health,  and  if  any 
member  of  this  audience  wishes  to  see  him,  he  works  at  No.  58 
Market  Street,  San  Francisco. 

7.  Syphilitic  Tuberculce. — Before  these  have  made  much  prog- 
ress they  resemble  papulae.  These  tumors  are  generally  small, 
solid,  and  deepseated,  and  differ  from  papulae  especially  in  the  strong 
tendency  to  ulceration  which  they  always  exhibit. 

Simple  tubercles  may  either  be  distinct  or  appear  in  groups ;  in 


480          LECTURES  ON  PRACTICAL  SURGERY. 

the  latter  form  they  are  small,  round,  and  arranged  in  circles,  each 
tubercle  being  covered  with  a  thin,  grayish-colored  scab.  They  are 
generally  indojent,  and  may  terminate  by  resolution,  without  leaving 
a  cicatrix.'  Sometimes  the  groups  are  very  irregular,  and  present 
the  copper  color  more  distinctly  than  any  other  variety,  and  after 
existing  for  a  considerable  time  ulceration  frequently  occurs. 

Tubercles  are  generally  large,  flat,  oval,  or  spherical.  They  oc- 
casionally remain  smooth  and  polished,  but  more  frequently  they 
are  covered  with  thin  scales.  After  ulceration  occurs,  however, 
thick  scabs  are  formed.  From  this  variety  of  the  disease,  the 
greatest  proportion  of  the  extensive  phagedenic  and  serpiginous 
ulcers  result.  The  former  not  unfrequently  destroy  the  skin  and 
cellular  tissue  so  extensively  as  to  expose  the  muscles  and  bones. 
The  edges  of  the  ulcerated  surface  resulting  from  their  extension  are 
both  elevated  and  abrupt ;  the  surface  is  either  gray  or  blackish,  and 
interspersed  with  bleeding  points. 

They  are  exceedingly  painful,  and  furnish  a  bloody  or  red  secre- 
tion ;  ulcers  of  this  character  are  common,  and  frequently  appear 
upon  the  penis,  mons  veneris,  and  the  extremities,  and  heal  slowly 
and  with  difficulty. 

Phagedenic  ulcers  are  common  in  scrofulous  patients,  or  in  those 
debilitated  either  by  chronic  disease  or  intern  pen  nee. 

Tubercular  serpiginous  ulcers  are  more  superficial  than  the  preced- 
ing, and  may  appear  upon  any  portion  of  the  body,  but  more  fre- 
quently upon  the  face  and  trunk.  Before  ulceration  occurs  they 
are  smooth,  with  a  brownish-violet  base,  which  is  characteristic  of 
almost  all  syphilitic  eruptions.  They  are  called  serpiginous  because 
they  heal  on  one  side  whilst  they  extend  on  the  other,  and  leave  a 
track  upon  the  skin  which  may  be  traced  by  the  dark  color  that  re- 
mains after  cicatrization  has  been  completed,  the  convolution  and 
spiral  course  of  which  resemble  the  windings  of  a  serpent.  They 
are  more  common  upon  the  back  and  anterior  portion  of  the  chest, 
although  they  may  occur  upon  the  face.  They  are  less  destructive 
than  the  phagedenic  ulcers,  although  equally  obstinate. 


LECTURE    XLVIII.  —  SECONDARY    SYPHILIS.  481 


LECTURE 

GENTLEMEN  :  In  this  lecture  the  secondary  affections  known  as 
alopecia,  onychia,  syphilitic  rheumatism,  syphilitic  sarcocele,  syphi- 
litic gummy  tumors,  syphilitic  conjunctivitis,  and  syphilitic  iritis  will 
be  considered. 

Alopecia. — If  by  this  term  we  are  to  understand  an  entire  and  uni- 
versal loss  of  the  hair,  it  is  highly  probable  that  at  an  earlier  period 
in  the  history  of  syphilitic  affections  it  was  a  much  more  common 
occurrence  than  at  present.  A  partial  difficulty  of  this  character, 
even  during  the  existence  of  both  primary  and  secondary  affections, 
is  not  unfrequent.  Generally  it  appears  to  result  from  a  disease  of 
the  skin,  in  which  there  occurs  a  slight  desquamation  of  the  cuticle, 
which  is  followed  by  a  thinning  of  the  hair,  eyebrows,  and  whiskers. 

The  cutaneous  affection,  known  by  the  slight  desquamation  and 
discoloration  that  exists,  and  by  which  it  is  evidently  produced,  is 
so  inconsiderable  as  either  not  to  attract  attention  or  to  be  considered 
as  a  simple  case  of  pityriasis  versicolor,  resulting  from  derangement 
of  the  hepatic  secretion,  and  can  only  be  distinguished  from  that 
affection  by  the  complication  above  indicated.  Complete  and  uni- 
versal alopecia,  as  I  before  stated,  seldom  occurs,  and  then  only  in 
patients  in  whom  the  entire  system  is  poisoned  by  the  virus.  When 
the  disease  is  partial,  the  true  skin  is  not  implicated,  and  so  soon  as 
the  constitutional  affection  is  controlled,  the  hair  is  reproduced ;  but 
when  it  appears  at  a  later  period,  during  the  existence  of  venereal 
cachexia,  and  is  entire,  it  is  then  a  much  more  serious  difficulty,  and 
even  under  the  most  judicious  treatment  is  frequently  unmanage- 
able, because  the  pilous  bulbs  are  so  seriously  affected  that  their 
functions  are  destroyed.  No  symptom  that  could  occur  during  the 
progress  of  the  disease  is  more  unpleasant,  in  consequence  of  the 
decided  and  undesirable  change  it  produces  both  in  the  appearance 
and  expression  of  the  face. 

Onychia. — The  matrix  of  the  nail,  as  the  consequence  of  the  exist- 
ence of  a  venereal  affection,  sometimes  inflames,  becomes  thickened 

31 


482  LECTURES    ON    PRACTICAL    SURGERY. 

and  furnishes  a  morbid  secretion,  accompanied  with  both  a  discolora- 
tion and  a  brittleness  of  the  nail  ;  or  it  ulcerates,  by  which  the  nail 
is  detached  from  its  connections,  and  is  easily  removed.  If  the  ma- 
trix ulcerates  only,  and  is  not  destroyed,  the  nail  is  reproduced  so 
soon  as  the  progress  of  the  constitutional  affection  is  arrested.  That 
cannot  occur,  however,  if  the  matrix  be  destroyed,  for  it  would  be 
as  rational  to  suppose  that  a  bone  could  be  reproduced  without  the 
preservation  of  the  periosteum,  as  that  without  the  matrix,  or  bulb, 
either  a  hair  or  a  nail  could  be  restored.  The  place  occupied  by  the 
nail,  in  cases  where  there  is  an  entire  destruction  of  the  matrix,  is 
represented  by  a  cicatrix,  with  probably  a  few  irregular,  horny  ex- 
crescences, which  do  not  in  the  slightest  degree  resemble  the  original 
formation.  The  affection  frequently  occurs  after  the  disappearance 
of  either  a  cutaneous  eruption  or  rheumatism,  and  when  ulceration 
exists,  it  is  sometimes  so  painful  as  to  prevent  sleep.  Some  time 
ago  I  treated  a  case  in  this  city  which  had  been  preceded  both  by  a 
papular  eruption  and  by  rheumatism,  and  was  confined  to  the  fingers 
of  the  right  hand.  Although  the  matrix  of  the  nails  was  so  vio- 
lently inflamed  that  an  abundant  and  offensive  purulent  discharge 
was  produced,  the  disease  yielded  to  the  ordinary  treatment,  and  no 
material  change  in  the  appearance  of  the  nails  resulted. 

Syphilitic  Rheumatism. — This  may  either  precede  or  occur  after 
the  disappearance  of  the  syphilides,  and  may  be  located  either  in  the 
muscles,  tendons,  or  aponeuroses.  During  the  first  stage  it  is  often 
accompanied  with  violent  pain,  particularly  during  muscular  action, 
and  may  be  mistaken  for  a  simple  rheumatic  affection,  from  which 
it  is  often  with  difficulty  distinguished,  if  the  history  of  the  case 
is  not  considered.  When  more  advanced,  the  muscles  frequently 
become  permanently  contracted,  and  particularly  the  biceps  of  the 
arm ;  the  contraction  may  continue  until  partial  or  complete  anchy- 
losis of  the  joints  results.  When  located  either  in  the  tendons  or 
joints,  they  frequently  swell,  and  occasionally  an  abundant  serous 
secretion  occurs,  which  is  both  painful  and  inconvenient.  If  neglected, 
tumors,  called  nodes,  are  developed  either  in  the  muscles  or  tendons, 
which  sometimes  become  solid.  At  first  a  serous  and  plastic  secre- 
tion is  deposited,  either  between  the  muscular  fibres  or  in  the  fibrous 
tissue  of  the  tendons,  and  gives  great  pain  whenever  the  muscles 
contract.  Suppuration  occasionally,  though  rarely,  occurs;  and  in 
this  respect  the  progress  is  not  unlike  that  of  ordinary  rheumatic  in- 


LECTURE    XLVIII.  —  SECONDARY    SYPHILIS.  483 

flammation.  When,  however,  the  local  inflammation  is  very  con- 
siderable, and  is  accompanied  with  fever,  suppuration  sometimes 
takes  place  in  the  centre  of  the  muscles,  from  which  extensive  de- 
struction of  tissue  often  results.  More  frequently,  when  neglected, 
the  deposits  are  converted  into  fibrous  or  osseous  tumors,  and  then, 
although  the  virus  may  be  eradicated,  they  are  exceedingly  difficult  to 
remove,  either  by  local  or  constitutional  treatment.  They  are  gen- 
erally located  in  the  biceps,  pectoralis  major,  vastus  externus,  or  tra- 
pezius,  and  not  unfrequently  in  the  muscles  of  the  eye  and  tendons 
of  the  fingers.  Several  cases  of  the  latter  variety  have  fallen  under 
my  observation. 

A  very  obstinate  and  distressing  case  of  syphilitic  rheumatism  was 
treated  recently  in  this  city,  in  which  both  the  joints  and  muscles 
were  affected,  accompanied  with  permanent  contraction  of  the  latter, 
and  with  enlargement  and  partial  anchylosis  of  the  former.  The 
biceps  of  the  left  arm  was  contracted  without  enlargement,  and  the 
ankle  and  knee-joints  of  the  same  side  were  painful,  swollen,  and 
almost  completely  anchylosed.  Soon  after  the  disease  was  contracted, 
the  patient  left  in  consequence  of  the  supervention  of  a  pulmonary 
affection ;  and  after  remaining  away  five  months,  returned  greatly 
emaciated,  with  loss  of  appetite,  with  constant  fever,  and  in  the  con- 
dition in  which  I  before  described.  Believing  mercurials  to  be  in- 
admissible in  his  prostrated  condition,  iodide  of  potassium,  with  the 
extract  of  actea  racemosa,  were  administered  as  I  shall  hereafter  de- 
scribe, and  in  ten  days  the  pains  disappeared  entirely,  his  appetite 
returned,  and  being  allowed  animal  food  ad  libitum,  in  two  weeks 
he  was  able  to  take  moderate  exercise.  The  motion  of  the  joints  was 
gradually  restored  by  forcible  flexion  and  extension  under  the  influ- 
ence of  chloroform,  and  the  use  of  the  limbs  is  now  as  perfect  as  be- 
fore the  occurrence  of  the  disease. 

Syphilitic  rheumatism  is  so  common  that  the  syphilides  seldom 
exist  long  without  being  accompanied  with  this  affection,  which  is 
one  of  the  most  distressing  complications  that  could  occur.  As  I 
before  said,  when  it  supervenes  during  the  early  stages,  symptoms  of 
inflammation  only,  such  as  pain,  increased  heat,  and  swelling,  exist, 
but  subsequently,  after  the  system  has  become  poisoned  by  the  virus, 
deepseated  abscesses  or  nodes  are  developed,  either  in  the  muscles, 
tendons,  or  aponeuroses,  and  then  it  becomes  not  only  serious  but 
highly  dangerous. 


484  LECTURES    ON    PRACTICAL    SURGERY. 

Syphilitic  Sarcocele. — After  the  cicatrization  of  a  chancre,  or  dur- 
ing the  existence  of  any  variety  of  secondary  disease,  or  even  after 
they  have  disappeared  without  the  virus  being  eradicated,  a  patient 
frequently  complains  of  pain  in  the  loins  and  uneasiness  in  one  or 
both  testicles.  At  first,  they  present  but  little  change,  either  in  ap- 
pearance or  density;  subsequently,  however,  the  glands  are  more 
painful,  particularly  at  night,  enlarge  slowly,  and  become  more  solid 
and  heavy.  The  increase  in  magnitude  appears  to  take  place  by 
lamellae,  and  the  solidity  is  in  proportion  to  the  time  it  has  existed. 
Although  the  disease  generally  commences  in  one  testicle,  they  both 
very  soon  become  implicated. 

This  affection  is  decidedly  chronic,  not  very  dangerous,  and 
although  by  neglect  it  may  destroy  the  organs  by  suppuration,  if 
properly  treated  such  a  result  should  not  be  apprehended.  The 
most  striking  peculiarity  in  the  progress  of  this  disease  is,  that 
although  the  testicle  may  enlarge  considerably,  become  very  hard 
and  painful,  the  original  form  of  the  organ  is  preserved. 

It  may  be  readily  distinguished  from  orchitis  by  the  rapid  prog- 
ress of  the  latter,  and  the  almost  entire  exemption  of  the  epididy- 
mis,  which  in  orchitis  becomes  affected  before  the  glandular  structure 
is  implicated.  In  orchitis  the  scrotum  is  more  or  less  distended  with 
serum,  the  pressure  of  which  upon  the  inflamed  organ  produces  the 
excessive  pain  by  which  the  disease  is  accompanied,  and  which  does 
not  occur  in  the  difficulty  under  consideration. 

In  strumous  enlargement  of  the  testicle  the  gland  is  less  solid,  the 
surface  more  irregular,  and  it  generally  occurs  in  subjects  of  a  de- 
cidedly scrofulous  diathesis. 

When  malignant  disease  exists  in  this  locality,  it  is  almost  always 
confined  to  one  testicle,  and  after  it  has  made  sufficient  progress  to 
excite  attention,  the  skin  soon  becomes  implicated,  which  rarely  takes 
place  in  syphilitic  sarcocele.  This  disease  is  decidedly  chronic,  and 
may  exist  several  years  without  undergoing  much  change,  although 
when  neglected  it  either  impairs  or  completely  destroys  the  sexual 
power,  in  consequence  of  the  entire  cessation  or  diminution  of  the 
seminal  secretion.  But  if  properly  treated  before  the  glandular 
structure  of  the  organs  is  destroyed,  although  they  may  become 
slightly  atrophied,  or  even  diminished  considerably  in  size,  impo- 
tence does  not  necessarily  follow.  For  want  of  confidence,  many 
imagine  themselves  in  that  condition  when  it  does  not  really  exist. 


LECTURE    XLVIII.  —  SECONDARY    SYPHILIS.  485 

Complete  and  irremediable  impotence  is  very  rare,  even  after  both 
testicles  have  suffered  from  the  disease. 

Syphilitic  Gummy  Tumors. — In  this  variety  of  secondary  syphilis 
the  cellular  tissue  only  is  implicated,  and  the  skin,  for  a  long  time 
after  it  becomes  indurated,  remains  in  a  normal  condition.  They 
usually  appear  after  the  system  has  become  seriously  affected  by  the 
poison,  and  are  generally  located  near  the  bones  or  upon  parts  where 
nothing  but  cellular  tissue  intervenes  between  them  and  the  skin, 
although  they  may  appear  upon  almost  every  portion  of  the  body. 

They  vary  greatly  in  size,  are  movable,  appear  to  be  encysted,  are 
extremely  indolent,  and  contain  a  gluey  matter  which  resembles  a 
mucilage  made  of  gum  tragacanth.  They  are  genuine  abscesses  that 
are  exceedingly  indolent,  and  contain  pus  only  after  a  protracted  in- 
flammatory action.  Usually  they  are  developed  in  the  cellular  tissue 
that  unites  the  skin  and  bones,  as  upon  the  cranium,  clavicles,  ribs, 
tibia,  radius,  or  ulna.  Sometimes  they  appear  elsewhere,  but  almost 
always  upon  parts  that  are  either  ligamentous  or  aponeurotic. 
Generally  their  appearance  is  preceded  by  dull  pains  in  the  part  af- 
fected, although  many  cases  occur  in  which  neither  pain  nor  uneasi- 
ness is  experienced.  Under  certain  circumstances,  these  tumors  be- 
come more  solid,  acquire  the  magnitude  of  a  walnut,  and  remain 
several  years  indolent,  but  if  not  arrested  by  proper  treatment,  they 
ultimately  inflame  and  discharge  a  ropy  substance,  which  may  either 
be  white,  transparent,  yellowish,  or  red. 

Two  very  distinct  cases  of  this  character  have  been  quite  recently 
treated.  In  one,  which  occurred  in  the  interior  of  this  State,  there 
were  three  tumors  nearly  the  size  of  quail  eggs.  They  were  appar- 
ently encysted,  and  very  movable.  Two  were  situated  upon  the 
lateral  and  anterior  portions  of  the  parietal  bones,  and  the  third  near 
the  external  angle  of  the  left  eye. 

The  tumors  were  regarded  by  a  physician  as  condylomata,  and  two 
of  them  were  extracted.  The  wounds  made  for  their  removal  re- 
fused to  heal,  and  a  proposition  being  made  for  a  second  operation, 
the  patient  determined  to  visit  San  Francisco.  I  was  induced  to 
believe  that  they  were  syphilitic  gummy  tumors  by  the  history  of 
the  case,  the  general  condition  of  the  patient,  and  the  copper  color  of 
the  ulcers  that  occupied  the  original  site  of  the  tumors,  which  charac- 
terizes all  secondary  syphilitic  affections.  Antisyphilitic  treatment 
was  prescribed,  and  in  fifteen  days  the  tumor  that  had  not  been  sub- 


486          LECTURES  ON  PRACTICAL  SURGERY. 

jectecl  to  treatment  disappeared  entirely  ;  but  the  ulcers  required  the 
continuance  of  the  treatment  for  several  weeks  before  cicatrization 
was  complete.  Under  this  course  his  general  health  improved 
rapidly,  and  both  the  tumor  and  ulcer  disappeared  without  any  local 
treatment,  which  would  not  have  occurred  if  they  had  been  simple 
encysted  tumors. 

In  the  other  case,  five  tumors  as  large  as  walnuts  were  situated 
upon  the  posterior  part  of  the  pelvis,  and  had  made  but  little  prog- 
ress for  some  years.  They  were  simply  inconvenient,  until  a  short 
time  before  he  applied  to  me  for  advice,  when  they  suddenly  inflamed, 
became  painful,  and  suppurated.  Extensive  ulcers  followed,  which 
yielded  to  specific  treatment.  The  firmness  of  the  tumors  resulted 
from  the  great  distension  and  thickness  of  the  cellular  tissue  of 
which  the  cysts  Were  composed.  These  tumors,  before  suppuration 
takes  place,  are  often  mistaken  for  condylomata,  and  are  subjected  to 
surgical  treatment;  after  ulceration  occurs,  thev  are  frequently  con- 
sidered cancerous,  and  unsuccessful  attempts  are  made  to  extirpate 
them. 

Syphilitic  Conjunctivitis. — This  variety  of  conjunctivitis  is  exceed- 
ingly common  in  California,  and  may  precede,  accompany,  or  succeed 
any  syphilitic  affection  either  of  the  skin  or  throat.  The  eye, 
although  excessively  red,  is  seldom  very  painful.  This  may  readily 
be  distinguished  from  any  other  variety  of  conjunctivitis  of  appar- 
ently the  same  violence,  by  the  entire  absence  of  photophobia,  which 
is  one  of  the  most  distressing  symptoms  in  simple  inflammation  of 
this  membrane.  It  is  generally  chronic,  and  rarely  affects  the  cor- 
nea, unless  greatly  neglected.  Whenever  one  or  both  eyes  are  ex- 
cessively red,  and  the  patient  can  face  a  strong  light  without  lachry- 
mation,  upon  inquiry  the  existence  of  syphilitic  symptoms  will  be 
proved,  or  will  be  found  to  have  preceded  the  difficulty.  For  its 
removal,  constitutional  treatment,  in  combination  with  the  simplest 
local  applications,  is  invariably  successful. 

Syphilitic  Iritis. — This  is  a  much  more  serious  affection  of  the  eye 
than  the  preceding,  and  as  in  that  variety,  it  may  precede,  exist  in 
combination  with,  or  succeed  the  syphilides,  although  it  is  more  fre- 
quently preceded  by  papular  eruptions  than  by  any  other  syphilitic 
cutaneous  disease.  Syphilitic  iritis  is  accompanied  with  pain  in  the 
eye,  temple,  or  anterior  portion  of  the  head,  and  is  generally  more 
violent  at  night.  Increased  vascularity,  both  of  the  conjunctiva  and 


LECTURE    XLVIII.  —  SECONDARY    SYPHILIS.  487 

cornea,  exists,  although  not  to  the  same  extent  as  when  the  disease  is 
of  an  exanthematous  character  and  entirely  external.  The  motion 
of  the  iris  being  impaired,  the  pupil  is  generally  irregular,  which 
results,  most  probably,  from  an  effusion  of  lymph,  and  consequently 
the  existence  of  bands  or  adhesions  by  which  portions  of  that  mem- 
brane are  fixed,  so  that  it  cannot  obey  the  stimulus  of  light.  Vision 
is  generally  disturbed  and  sometimes  entirely  destroyed.  The  dark 
color  of  the  iris  is  changed  to  a  greenish  hue  by  the  lymph  effused, 
which  may  be  deposited  either  in  the  anterior  or  posterior  chambers, 
or  even  upon  the  posterior  surface  of  this  membrane,  in  which  locality 
small  abscesses  of  the  iris  appear  in  cases  of  long  standing. 

In  syphilitic  iritis,  the  fluid  effused,  whether  serum  or  lymph,  is 
sometimes  so  abundant  that  even  the  sclerotic  yields  to  the  profuse 
flow,  and  staphyloma  of  that  membrane  is  produced. 

A  very  remarkable  case  of  this  description  was  reported  by  me, 
some  time  since,  in  which,  after  long-continued  and  most  intense 
suffering,  staphyloma  of  the  sclerotic  made  its  appearance  upon  the 
superior  portion  of  the  eye,  with  entire  loss  of  vision.  After  the 
progress  of  the  disease  was  arrested,  iridectomy  was  performed,  by 
which  not  only  was  the  staphyloma  cured,  but  vision  was  restored. 

Syphilitic  iritis  progresses  much  less  rapidly  than  traumatic,  and 
is  less  destructive  to  the  organ.  It  may  change  from  one  eye  to  the 
other  without  being  influenced  by  treatment,  and  the  patient  suffers 
less  from  photophobia  than  in  simple  inflammation  of  that  mem- 
brane, although  a  violent  paroxysm  of  pain  is  almost  always  expe- 
rienced at  night. 

No  individual  symptom  will  indicate  positively  the  character  of 
syphilitic  iritis,  although,  by  carefully  examining  the  throat,  skin,  or 
anus,  evidences  of  syphilitic  disease  can  almost  always  be  detected. 
Sometimes  syphilitic  iritis  is  complicated  with  rheumatism,  and  then 
but  little  difficulty  will  be  experienced  in  determining  its  character. 
Should  iritis  occur  without  an  apparent  cause,  such  as  wounds,  exter- 
nal violence,  or  great  and  protracted  exertion  of  the  organ,  a  specific 
cause  should  be  suspected,  and  if  not  positively  ascertained,  no 
serious  or  permanent  injury  or  inconvenience  can  result  from  the 
administration  of  specific  remedies.  Many  eyes  are  lost  that  might 
be  saved  without  difficulty  by  proper  treatment,  as  a  sufficient  time 
always  elapses  between  the  commencement  of  the  disease  and  the 
destruction  of  the  organ,  to  obtain  the  full  effect  of  efficient  remedies. 


488  LECTURES    ON    PRACTICAL    SURGERY. 

I  regret,  however,  that  the  same  cannot  be  said  of  gonorrhoeal 
ophthalmia,  which  is  the  most  violent  and  destructive  disease  to 
which  this  organ  is  exposed,  and  the  only  one,  which,  if  properly 
managed,  should  under  any  circumstances  destroy  either  its  struc- 
ture or  its  functions ;  although  even  this,  if  treated  early  and  ener- 
getically, may  be  arrested,  and  the  organ  restored  both  to  health  and 
usefulness. 


LECTURE   XLIX.  —  SECONDARY   AND    TERTIARY   SYPHILIS.       489 


LECTURE  XLIX. 


LIB  II  A  U 

UNIVERSITY 

CALIFORNI 


TREATMENT   OF   SECONDARY   AND   TERTIARY   SYPHILIS. 

GENTLEMEN:  The  preceding  lectures  upon  the  subject  of  syphilis 
were  devoted  to  descriptions  of  the  clinical  history,  the  various  compli- 
cations, the  diagnosis,  and  the  termination  of  the  different  forms  of 
the  disease.  The  present  lecture  will  be  devoted  to  the  treatment 
of  the  secondary  and  tertiary  forms  of  the  disease. 

In  the  treatment  of  secondary  syphilis  it  is  not  sufficient  for  the 
physician  to  know  the  number  of  antisyphilitic  remedies,  but  he 
should  also  be  sufficiently  familiar  with  their  specific  action  to  adopt 
the  course  of  treatment  best  calculated  to  control  the  variety  with 
which  he  has  to  contend.  A  repetition  of  what  I  have  said  in  a 
previous  lecture  upon  the  treatment  of  primary  syphilis  will  not 
now  be  necessary.  With  the  exception  of  complicated  and  obstinate 
cases  of  constitutional  disease,  the  general  course  of  treatment 
which  I  then  described  will  be  found  as  efficacious  in  the  secondary 
as  in  the  primary  forms  of  the  disease. 

When,  however,  secondary  syphilis  resists  mercurials,  sudorifics, 
and  tonics,  they  should  be  abandoned  and  other  means  adopted, 
which  may,  in  consequence  of  the  existence  of  constitutional  idiosyn- 
crasy, accomplish  more  than  remedies  of  greater  general  value.  The 
most  celebrated  of  these  which  have  not  already  been  mentioned 
are : 

1st.  Ptisane  de  Feltz,  the  active  ingredient  of  which  is  the  native 
sulphuret  of  antimony,  which  has  unquestionably,  in  many  aggra- 
vated cases,  exerted  a  very  salutary  influence. 


490          LECTURES  ON  PRACTICAL  SURGERY. 

2d.  Ptisane  de  Vigaroux,  which  is  composed  of  the  following  in- 
gredients : 

R — Had.  snrsaB  opt., 4  Ibs. 

Sennae  fol.,        ........     3  Ibs. 

Guaiac.  lig., 
Potass,  bitartratis, 
Aristolochise  long., 

"  rotund., 

Sassafras,  cort.  rad., 
Ead.  iridis, 
Ant.  sulpbureti, 
Anisi  sem., 
Jalapge  rad., 
Polypodii, 
Smilacis  Chinse,  iia          ......     l\  Ibs. 

Vini  alb.,       ..." 2£  Ibs. 

To  which  add  13  J  Ibs.  of  water,  and  digest  for  twenty-four  hours 
in  a  sand-bath.  Decant,  and  evaporate  to  six  pounds.  Dose,  three 
wineglasses  a  day. 

3d.  Ptisane  d'Arnaux : 

R — Liq.  guaiac., 
Ichthyocollae, 
Cort.  mezerei  rad., 
Cornus  Florida,  aa          .....     1  lb.,  9  oz. 

Aquae, 4  Ibs.,  6  oz. 

Infuse. 

4th.  Ptisane  de  Lisbonne  : 

R — Rad.  sarsaa  opt., 

Santali  rubri,  aa     .         .         .         .         .         .2  Ibs.,  6  oz. 

Rhodii  lig., 

Guaiaci,  aa     .......  1  oz. 

Cort.  mezerei  rad.,          .....  £  oz. 

Ant.  sulphureti,      ......  2  oz. 

Sassafras,  rad.,        ......  1  oz. 

Aquse,     ........     8  Ibs. 

.. 

Infuse  during  the  night,  and  in  the  morning  add  one  oz.  ext. 
glycyrrhizse,  and  boil  until  reduced  one-half. 

The  ingredients  of  these  remedies  I  give  you  because  they  are  not 
generally  used,  and  may  be,  in  obstinate  and  difficult  cases,  of  im- 
mense advantage,  for  many  are  met  in  California  which  baffle  for 
many  months  the  skill  of  the  most  scientific  and  experienced. 


LECTURE   XLIX.  —  SECONDARY   AND   TERTIARY   SYPHILIS.        491 

Muriate  of  gold  was  formerly  regarded  as  a  specific  in  the  treat- 
ment of  every  variety  of  constitutional  syphilis,  although  at  present 
it  is  restricted  almost  exclusively  to  cases  that  have  resisted  the  or- 
dinary remedies.  From  one-sixth  to  half  a  grain  may  be  rubbed 
upon  the  gums  twice  a  day,  or  one-sixteenth  of  a  grain  may  be  given 
internally  morning  and  evening. 

Platinum  may  be  alternated  with  the  muriate  of  gold,  as  it  is 
applicable  to  the  same  class  of  cases,  and  is  administered  in  the  same 
doses. 

In  chronic  and  obstinate  syphilitic  cutaneous  affections  that  resist 
mercurials,  arsenic  administered  in  combination  with  the  extract  of 
stillingia  sylvatica,  the  compound  decoction  of  sarsaparilla,  or  the 
ptisanes  before  mentioned,  in  doses  varying  from  one-tvN7elfth  to  one- 
sixteenth  of  a  grain,  three  times  a  day,  will  in  many  cases  be  found 
very  useful,  and  should  be  administered  when  you  are  disappointed 
by  remedies  of  better  established  efficacy,  for  if  not  sufficiently  active 
to  eradicate  the  poison,  the  progress  of  the  disease  may  be  arrested 
until  the  susceptibility  of  the  system  to  the  action  of  specific  reme- 
dies is  restored. 

Besides  those  that  I  have  just  mentioned,  there  are  many  other 
remedies,  both  mineral  and  vegetable,  that  have  been  both  recom- 
mended and  strongly  advocated,  but  which  have  not  been  found  to 
possess  enough  importance  to  render  it  necessary  that  they  should 
even  be  enumerated.  In  chronic  cases,  complicated  with  a  decidedly 
cachectic  diathesis,  the  preparations  of  iron  are  not  only  considered 
useful,  but  are  unquestionably  very  important  remedies,  when  ad- 
ministered either  alone  or  in  combination  with  vegetable  tonics  and 
sudorifics. 

The  tartrate  of  potassa  and  the  solution  of  the  perchloride  of  iron 
are  regarded  as  the  most  efficacious.  The  former  has  been  both  rec- 
ommended and  prescribed  by  Ricord  as  an  infallible  remedy  in  the 
treatment  of  primary  syphilis,  although  the  result  of  my  experience, 
in  the  cases  in  which  it  is  considered  most  effectual,  compels  me  to 
consider  it  of  much  less  importance  as  an  antisyphilitic  remedy 
than  it  appeared  to  its  distinguished  discoverer  and  advocate.  It  is, 
however,  in  the  cases  before  mentioned,  much  more  useful,  and  fre- 
quently exerts  a  decidedly  beneficial  influence.  A  solution  composed 
of  six  drachms  of  the  tartrate  of  potassa  to  four  ounces  of  simple 


492          LECTURES  ON  PRACTICAL  SURGERY. 

syrup,  may  be  administered  in  teaspoonful  doses  three  or  four  times 
a  day,  until  the  desired  effect  is  produced. 

The  perchloride  of  iron,  however,  I  have  found  more  decidedly 
useful ;  twenty  drops  of  the  solution  in  a  wineglassful  of  water  may 
be  administered  morning,  noon,  and  night ;  and  when  sufficiently  di- 
luted, enters  the  circulation,  and  although  it  may  not  exert  a  specific 
influence,  it  certainly  invigorates  the  system,  arrests  the  progress  of 
the  disease,  and  thereby  affords  an  opportunity  to  prescribe  specific 
treatment  successfully.  In  the  treatment  of  syphilitic  rheumatism, 
in  addition  to  the  ordinary  remedies,  either  when  the  disease  exists 
alone  or  is  complicated  with  the  syphilides,  I  have  found  the  extract 
of  actea  racemosa  invaluable.  When  simple,  the  iodide  of  potas- 
sium, tincture  of  aconite  root,  extract  of  actea  racemosa,  combined 
with  simple  syrup  or  the  compound  syrup  of  sarsaparilla,  will  act 
more  speedily  and  effectually  than  any  other  combination.  About 
thirty  drops  of  the  extract  of  actea  should  be  administered  three  or 
four  times  daily,  according  to  the  susceptibility  of  the  patient.  When 
syphilitic  rheumatism  exists  in  combination  with  other  secondary 
symptoms,  the  deutochloride  of  mercury  should  be  combined  with 
the  drugs  before  mentioned,  in  the  proportion  of  four  grains  to  a  five 
or  six-ounce  mixture,  and  administered  as  before  directed. 

In  the  treatment  of  secondary  syphilis,  it  is  of  the  greatest  im- 
portance to  attend  especially  to  the  general  health,  for  if  that  becomes 
impaired  the  remedies  prescribed  will  not  exert  their  usual  influence. 
If  the  general  health  should  fail,  the  mercurials  should  be  suspended, 
and  tonics  substituted  until  the  system  is  sufficiently  invigorated  to 
resist  the  debilitating  influence  of  the  mercurial  course.  Nothing  is 
so  injurious,  and  in  many  cases  destructive,  to  the  patient  when  suf- 
fering from  constitutional  syphilis,  as  the  rigid  diet  formerly  pre- 
scribed. For  so  soon  as  the  system  becomes  enfeebled  by  such  treat- 
ment during  the  administration  of  even  the  mildest  mercurials, 
diarrhoea  almost  always  supervenes,  which  is  frequently  more  serious 
and  difficult  to  control  than  the  specific  affection  for  which  the  mer- 
curial course  is  prescribed. 

The  time  necessary  to  continue  the  treatment  in  such  cases  varies 
with  the  duration  of  the  disease  and  its  complications.  The  rule 
adopted  by  Dupuytren  was  to  continue  it  as  much  longer  as  was 
found  necessary  to  remove  all  external  evidences  of  the  disease. 

Local  Treatment. — During  the  progress  of  the  syphilides,  warm 
baths,  two  or  three  times  a  week,  are  not  only  exceedingly  useful, 


LECTURE   XLIX. — SECONDARY   AND   TERTIARY   SYPHILIS.        493 

but  also  indispensable  to  the  comfort  of  the  patient,  although  the 
daily  use  of  the  steam  baths,  so  generally  prescribed  by  their  pro- 
prietors, cannot  be  too  strongly  reprobated.  They  are  not  only  in- 
jurious from  their  debilitating  effect,  but  also  highly  dangerous  in 
consequence  of  the  susceptibility  to  cold  being  greatly  increased, 
particularly  in  the  climate  of  San  Francisco,  where  variations  in 
temperature  are  both  sudden  and  considerable. 

Mercurial  fumigations  should  occasionally  be  recommended  in 
violent  and  aggravated  cases,  administered  as  I  have  before  described. 
In  the  treatment  of  extensive  ulcerations  of  the  skin,  the  most 
efficient  and  powerful  local  application  is  MonsePs  salt,  its  action 
being  as  prompt  and  satisfactory  as  in  the  primary  ulcer.  The  only 
objection  that  can  be  urged  against  its  universal  adoption  is  the  pain 
produced  in  excessively  irritable  ulcers  by  its  application.  If,  how- 
ever, only  a  small  quantity  of  the  salt  be  applied,  after  a  few  days 
the  irritability  is  destroyed,  the  surface  becomes  healthy,  the  eleva- 
tion and  the  induration  of  the  edges  disappear,  and  then  the  appli- 
cation of  this,  the  most  extraordinary  local  antisyphilitic  remedy  that 
has-  ever  been  discovered,  will  only  be  followed  by  temporary  incon- 
venience. Simple  cerate  should  be  applied  after  the  use  of  the  salt, 
and  if  the  ulcers  are  situated  upon  the  extremities  the  dressing  should 
be  retained  in  place  by  a  simple  roller.  Under  this  local  treatment, 
combined  with  the  constitutional  remedies  which  the  peculiarities  of 
the  case  require,  but  little  difficulty  will  be  experienced  in  the 
management  of  the  most  aggravated  cases  of  secondary  syphilitic 
ulceration. 

The  local  remedies  that  were  heretofore  prescribed,  and  that  are 
even  now  generally  prescribed  by  many  prejudiced  physicians,  are 
those  previously  described  as  applicable  for  the  treatment  of  primary 
ulcers,  and  what  was  then  said  upon  the  subject  need  not  now  be 
repeated.  Every  day's  experience  convinces  me  more  fully  of  their 
insignificance  when  compared  with  MonsePs  salt,  which  is  the  only 
local  application  which  I  employ  in  the  treatment  of  ulcers,  whether 
simple  or  specific,  and  it  is  exceedingly  gratifying  to  me  to  see  the 
high  encomiums  bestowed  upon  it  by  other  highly  respectable  and 
unprejudiced  physicians.  Dr.  Tibbetts,  of  Iowa  Hill,  in  referring  to 
its  use  in  such  cases,  says  that  its  haemostatic  powers  sink  into  insig- 
nificance when  compared  with  its  antisyphilitic  properties.  His 
language  is  both  appropriate  and  expressive,  and  explains  its  modus- 


494          LECTURES  ON  PRACTICAL  SURGERY. 

operandi  more  satisfactorily  than  any  other  terms  that  could  have 
been  employed. 

Tertiary  Syphilis. — Although  some  syphilographers  doubt  the  pro- 
priety of  designating  syphilitic  affections  of  the  osseous  system  as 
tertiary,  I  am  convinced  that  a  sufficient  number  of  well-authenti- 
cated cases  do  not  exist  to  establish  even  the  probability  of  the  oc- 
currence of  either  syphilitic  periostitis  or  ostitis  without  the  previous 
existence  of  secondary  symptoms.  Generally  after  the  appearance 
of  the  syph Hides,  whether  neglected  or  inefficiently  treated,  the  pa- 
tient complains  of  pain  in  one  or  more  of  the  superficial  bones,  which 
generally  increases  at  night,  and  may  continue  for  several  weeks  with- 
out the  existence  of  active  disease,  which  is,  however,  sooner  or  later 
invariably  developed. 

When  syphilitic  inflammation  is  located  in  the  periosteum,  it  is 
called  periostitis ;  when  either  upon  the  external  surface,  or  in  the 
internal  structure  of  the  bone,  it  is  designated  ostitis.  In  periostitis, 
after  the  inflammation  has  existed  for  some  time,  a  slight  elevation 
may  be  detected,  accompanied  with  pain  on  pressure,  and  without 
any  discoloration  of  the  skin,  although  the  pain  may  be  excessively 
annoying.  The  tumor  or  enlargement  in  this  variety  of  the  disease, 
has  received  the  appellation  of  node,  three  varieties  of  which  have 
been  recognized  and  described.  In  the  first  variety,  after  remaining 
hard  and  painful  for  a  few  weeks,  they  become  soft,  fluctuate  slightly, 
and  contain  a  serous  or  sero-albuminous  fluid,  which  resembles  either 
the  discharge  from  a  scrofulous  tumor  or  synovia.  The  second 
variety  is  accompanied  with  more  pain  ;  the  tumor  enlarges  rapidly, 
and  suppuration  speedily  occurs.  Although  the  third  variety  is 
generally  considered  as  the  result  of  periostitis,  the  inflammation 
frequently  extends  to  the  substance  of  the  bone,  and  a  tumor  is  pro- 
duced which  is  more  solid  than  that  which  I  have  just  described, 
and,  being  developed  in  lamellae,  may  readily  be  converted  into  bone 
or  exostosis,  and  belongs  properly  to  that  class  of  syphilitic  tumors. 

Ostitis. — It  is 'very  evident  that  ostitis  exists  in  many  cases  that 
are  regarded  as  instances  of  periostitis,  although  the  bone  may  be 
first  affected,  and  the  disease  subsequently  extend  to  its  investing 
membrane. 

When  the  external  surface  of  a  bone  inflames,  an  effusion  takes 
place  between  it  and  the  periosteum,  by  which  the  latter  is  detached 
and  a  tumor  developed.  In  other  cases  inflammation  may  take  place 


LECTURE   XLIX.  —  SECONDARY   AND   TERTIARY   SYPHILIS.        495 

in  the  parenchymatous  structure  of  the  bone,  and  exist  for  a  consid- 
erable time  without  presenting  any  other  evidence  of  disease,  except 
excessive  nocturnal  pains.  Ostitis  may  be  either  circumscribed,  or 
it  may  extend  to  the  entire  bone.  When  syphilitic  inflammation 
exists,  its  structure  presents  a  spotted  appearance,  and  grooves  speedily 
form,  in  which  both  red  blood  and  a  transparent  liquid  are  effused; 
subsequently  a  more  plastic  and  organizable  matter  is  deposited, 
which  produces  a  resemblance  to  the  third  variety  of  nodes. 

The  tumors  resulting  from  syphilitic  ostitis,  even  after  being 
long  painful,  are  not  well  denned,  being  more  diffuse  and  less  prom- 
inent and  distinct  than  in  cases  of  periostitis.  The  progress  of  ostitis 
may  generally  be  considered  as  chronic  when  compared  with 
periostitis,  although  the  induration  is  greater,  and  instead  of  ter- 
minating by  resolution,  suppuration,  or  gangrene,  the  enlargement 
becomes  both  the  seat  of  supernutrition  and  an  abnormal  ossifica- 
tion. 

Two  varieties  of  parenchymatous  exostoses  may  result  from  ostitis, 
the  compact  and  the  cellular.  In  the  cellular  variety,  bony  matter 
is  deposited  in  lamellae,  with  the  intervention  of  areoke ;  these  are 
called  laminae  or  lamellated  exostoses.  In  the  compact  variety,  the 
tissue  is  solid,  and  the  bone  acquires  both  increased  magnitude  and 
greater  density.  This  variety  is  known  as  exostosis  eburnee,  or  the 
ivory  exostosis.  These  tumors  present  considerable  variety  in  form, 
and  may  be  either  flat,  conical,  or  partially  pedunculated,  and  em- 
barrass the  organs  in  the  vicinity,  either  by  their  position  or  magni- 
tude. 

Exostoses  may  be  either  external  or  internal.  When  external, 
no  difficulty  will  be  experienced  in  forming  a  correct  diagnosis,  but 
if  situated  upon  the  internal  surface  of  the  bones  of  the  cranium, 
ribs,  clavicle,  or  vertebrae,  it  is  then  much  more  difficult  to  deter- 
mine the  cause  of  the  symptoms  and  the  character  of  the  disease.  It 
is  not  uncommon,  after  the  disappearance  of  secondary  symptoms, 
for  deepseated  pain  in  the  head  to  supervene,  which  is  generally 
regarded  as  neuralgic  or  rheumatic,  and  in  consequence  of  the 
absence  of  any  external  evidence  of  syphilis,  an  inefficient  treat- 
ment is  adopted  and  the  tumor  enlarges,  either  by  an  effusion 
between  the  bone  and  the  dura  mater  or  by  the  deposit  of  bony 
matter,  until  sufficient  pressure  is  exerted  upon  the  brain  to  pro- 
duce paralysis,  which,  in  tertiary  syphilis,  is  exceedingly  com- 


496  LECTURES    ON    PRACTICAL    SURGERY. 

mon,  and  is  frequently  attributed  both  by  the  patient  and  phy- 
sician to  the  treatment,  and  particularly  to  the  protracted  use  of 
the  iodide  of  potassium. 

This  remedy,  when  properly  administered,  never  produces  the 
difficulty  just  described,  and  the  paralysis  can  be  more  easily  and 
rationally  explained. 

When  exostoses  form  in  the  bodies  of  the  vertebrae,  the  spinal 
cord  may  be  subjected  to  sufficient  pressure  to  produce  either  partial 
or  complete  paralysis  below  the  point  affected.  Several  cases  have 
occurred  in  my  practice  in  tertiary  syphilis,  even  when  under  the 
influence  of  the  ordinary  treatment.  Whenever,  after  the  disap- 
pearance of  or  during  the  continuance  of  any  form  of  secondary 
syphilis,  deepseated  pain  is  experienced,  either  in  the  head  or  in 
the  vicinity  of  the  bones  protecting  the  cavities,  whether  constant  or 
periodical,  and  which  resists  the  ordinary  treatment  adopted  in  such 
cases,  the  existence  of  syphilitic  periostitis,  orostitis,  or  both,  should 
be  suspected,  and  if  not  efficiently  treated,  the  most  disastrous  if  not 
speedily  fatal  consequences  may  result. 

The  iodide  of  potassium  in  large  doses,  combined  with  the  deuto- 
chloride  of  mercury  and  other  efficient  remedies,  should  be  prescribed, 
and  if  timely  and  properly  administered  will  generally  arrest  the 
progress  of  the  most  serious  and  fatal  form  of  this  dreadful  disease. 

In  an  aggravated  case  of  tertiary  syphilis  that  occurred  in  this 
city,  the  patient  became  suddenly  and  completely  paralyzed,  with 
an  entire  loss  of  the  voice,  although  his  faculties  were  unimpaired, 
and  he  remained  ten  days  in  that  condition  before  death  occurred. 
The  brain,  in  this  case,  presented  no  evidence  of  disease,  although 
sufficient  pressure  was  exerted  upon  the  superior  part  of  the  spinal 
cord,  by  an  effusion  of  a  sero-albummous  fluid,  to  account  satisfac- 
torily for  the  occurrence. 

Caries  and  Necrosis. — In  caries  only  ulceration,  or  partial  morti- 
fication of  a  bone  exists,  while  in  necrosis  there  is  an  entire  loss  of 
vitality. 

The  bones  of  the  cranium  are  liable,  in  tertiary  syphilis,  to  both 
forms  of  the  disease.  Wrhen  the  pericranium  only  is  affected  the 
case  is  much  less  serious  than  when  this  membrane  and  the  bone  are 
both  implicated.  When  the  pericranium  is  detached  from  the  bone, 
caries  of  the  external  table  only  results ;  but  if  both  the  dura  mater 
and  the  pericranium  be  detached,  then  necrosis  of  the  denuded  por- 


LECTURE   XLIX.  —  SECONDARY   AND   TERTIARY   SYPHILIS.         497 

tion  of  the  bone  must  occur,  which  Vidal  considers  not  only  exceed- 
ingly serious,  but  also  that  the  complete  restoration  of  the  destroyed 


FIG.  83. 


bone  is  entirely  impossible.  In  this  I  am  convinced  he  is  mistaken, 
which  is  proved  conclusively  by  a  case  which  I  reported  some  years 
ago  in  the  Pacific  Medical  and  Surgical  Journal. 


498 


LECTURES  ON  PRACTICAL  SURGERY. 


In  that  case  necrosis  of  the  entire  os  frontis  existed,  which  was 
removed,  and  is  now,  having  been  often  examined  subsequently,  en- 
tirely restored.  Two-thirds  of  the  clavicle  were  also  excised  for  a 
similar  affection,  and  with  the  same  result. 

Both  the  bones  and  the  cartilages  of  the  nose  are  frequently  de- 
stroyed by  syphilitic  inflammation,  which  is  an  exceedingly  disagree- 
able and  unfortunate  occurrence,  both  in  consequence  of  the  offensive 
character  of  the  difficulty  and  of  the  deformity  which  generally 
results  from  its  ravages.  The  palate  bones  are  frequently  destroyed, 
and  this  difficulty  is  frequently  accompanied  with  ulceration  of  the 
soft  parts. 

A  very  unpleasant  case  of  this  kind  occurred  some  years  ago  in 


FIG.  85. 


San  Francisco,  in  which  an  opening  extended  from  the  mouth  to  the 
nasal  cavity,  an  inch  in  diameter.  After  the  disease  was  arrested, 
and  the  necrosed  bone  removed,  I  determined  to  make  an  effort  to 
remove  the  inconvenience  inseparable  from  such  a  difficulty  by  an 


LECTURE   XLIX. — SECONDARY    AND   TERTIARY   SYPHILIS.        499 

operation  which,  although  exceedingly  difficult,  has  been  entirely 
successful.  After  removing  the  edges  of  the  raucous  membrane  with 
a  bistoury,  three  silver  sutures  were  inserted  ;  lateral  incisions  were 
then  made,  an  inch  and  a  quarter  in  length,  on  each  side  of  the 


FIG.  8fi. 


opening,  and  half  an  inch  from  its  margins,  and  extending  to  the 
bone,  from  which,  between  the  incisions  and  the  margins  of  the 
opening,  the  mucous  membrane  was  entirely  detached,  which  enabled 
me  to  place  the  denuded  edges  in  direct  apposition.  When  the  su- 
tures were  removed  on  the  seventh  day  partial  union  was  effected, 
although  it  was  not  sufficiently  complete  to  afford  the  desired  relief. 
In  two  weeks  the  operation  was  repeated  with  the  result  before  men- 
tioned. 

This  operation  was  so  much  more  successful  than  was  anticipated, 
that  one  of  a  similar  character  has  been  performed  with  ultimate  suc- 
cess. Operations  of  this  character  are  much  more  tedious  than  those 
upon  the  soft  palate,  in  consequence  of  the  great  difficulty  usually 


500  LECTURES    ON    PRACTICAL    SURGERY. 

experienced  in  approximating  the  edges  and  inserting  the  sutures, 
which  results  from  the  form  and  location  of  the  part  affected. 

Whenever  a  bone  becomes  either  carious  or  necrosed  from  syphi- 
litic inflammation,  the  affected  part  should  be  excised  as  soon  as 
the  disease  is  arrested  by  proper  constitutional  treatment.  If  caries 
of  one  of  the  long  bones  exists,  the  diseased  portion  may  be  removed 
with  the  trephine,  and  if  necrosed,  by  any  means  that  will  effect 
that  object  most  readily. 

The  course  of  treatment  successfully  adopted  in  necrosis  of  the 
cranial  bones  having  been  before  described,  it  is  unnecessary  to  refer 
to  it  again,  and  in  conclusion  I  will  repeat  that  in  the  treatment  of 
tertiary  syphilitic  periostitis  and  ostitis,  accompanied  with  excessive 
pain,  the  application  of  leeches  may  occasionally  be  exceedingly  ad- 
vantageous, although  generally  every  means  should  be  adopted  that 
will  support  the  strength  and  improve  the  general  health,  for  upon 
that  depends  the  success  of  the  physician.  In  many  cases,  before 
specific  treatment  can  be  made  available,  the  general  health  must  be 
improved  by  tonics  and  generous  diet. 

Can  tertiary  syphilis  be  transmitted  from  parents  to  their  offspring? 
I  have  known  so  many  females  who  were  suffering  from  tertiary 
syphilis  bear  healthy  children,  that  I  cannot  believe  that  it  is  trans- 
missible. 


LI  It  K  A  !,'  V 

INI  VKKSITY   OF 

CALIFORNIA. 


APPENDIX. 


OPERATION  FOR  DEFORMITY  OF  NOSE  BY  INJURY. 

THIS  cut  represents  a  man  who  lost  the  end  of  his  nose.     It  was 
bitten  off  in  a  fight. 

FIG.  87. 


The  photograph  was  taken  before  the  operation  was  completed,  in 
order  to  exhibit  to  the  class  the  first  stage  ol  the  operation. 

33 


502 


APPENDIX. 


When  the  flap  adhered,  the  pedicle  was  divided,  and  now  he  is 
not  disfigured  at  all,  except  that  a  slight  scar  is  visible. 


ENCEPHALOID  TUMOR  '-OF  BONE. 

The  annexed  cut  represents  a  man,  named    Hoover,  who  had  a 
malignant  tumor  affecting  the  lower  jaw. 


FIG.  88. 


The  inferior  maxillary  bone  was  removed  with  the  tumor.     The 
disease  subsequently  returned  internally,  which  proved  fatal. 


APPENDIX. 


503 


EXCISION  OF  ELBOW. 

This  case  was  published  In  the  Transactions  of  our  State  Medical 
Society.  It  was  reported  to  the  Society  a  fe*v  years  after  the  opera- 
tion, the  patient  also  being  present,  when  the  meeting  was  held  i» 


FIG.  89. 


this  city.  His  name  was  John  Schultz,  set.  37.  The  bones  of  the 
elbow  were  diseased  as  the  result  of  an  old  injury ;  they  were  re- 
sected, a  chain  saw  being  used.  Fig.  89  shows  the  state  of  the  arm 
before  the  operation.  Fig.  90  exhibits  it  when  the  cure  was  effected. 


504 


APPENDIX. 


He  now  works  in  a  coal  yard,  and  is  as  efficient  as  any  man  em- 
ployed there.     The  entire  joint  was  removed ;  the  motion  is  perfect, 


FIG.  90. 


the  arm  is  as  strong  as  the  other,  and  the  only  difference  is  in  the 
length.  The  case  appeared  in  the  Transactions  of  the  California 
State  Medical  Society,  with  other  cases  of  a  similar  character. 


APPENDIX. 


505 


INJURY  OF  FOOT. — EXCISION  OF  BONES. 

This  patient,  John  Blockley  by  name,  was  a  teamster  who  traded 
from  Stockton  to  the  interior  of  the  State.  He  was  master  of  a  splen- 
did team,  and  what  is  called  in  this  country  a  "Prairie  Schooner," 
which  was  capable  of  carrying  about  ten  tons.  One  of  the  wheels 
passed  over  his  foot,  the  bones  of  the  foot  and  ankle  were  crushed, 


FIG.  91. 


and  he  came  to  me  to  have  his  leg  amputated.  He  was  emaciated 
from  diarrhoea  and  nightsweats,  and  was  afraid  his  foot  could  not 
be  saved.  I  removed  all  of  the  metatarsal  bones  at  the  first  operation ; 
in  about  a  week  all  of  the  tarsal  bones.  In  a  few  weeks  they  were 
reproduced. 

The  foot  is  now  as  healthy  and  useful  as  the  other,  except  that 
the  motion  of  the  ankle  joint,  although  considerable,  is  not  perfect. 


506 


APPENDIX. 


EXAMINATION  OF  THE  RECTUM. 

The  annexed  cuts  (Figs.  92  and  93),  represent  two  forms  of  rectum 
specula.     They  are  very  important  in  determining  the  character  of 


FIG.  92. 


FIG.  93. 


the  diseases  of  this  part,  and  particularly  of  internal  fistula,  which 
cannot  be  ascertained  without  the  use  of  a  speculum. 


INDEX. 


Abdomen,  wounds  of,  355. 

Abscesses,  multiple.  81. 

Absorption,  83. 

Alopecia,  481. 

Amaurosis,  415. 

Anaesthetics,  20. 

Aneurism,  161  ;  varicose,  174. 

Amputations.  255. 

Anodynes,  47. 

Arteries, wounds  of,  153 ;  ligation  of,  175. 

Bleeding,  40. 

Bones,  diseases  of,  309,  502. 

Brain,  injuries  of,  373  ;  tumors  of,  379. 

Breast,  diseases  of,  382. 

Bruises,  231. 

Bubo,  455. 

Bunions,  433. 

Burns,  245. 

Bursse,  339. 

Caries,  syphilitic,  496. 

Cataract,  416. 

Catarrh  of  bladder,  225. 

Cathartics,  43. 

Chancre,  441. 

Chest,  wounds  of,  348. 

Chilblains,  244. 

Club-foot,  104. 

Colloid,  135. 

Congestion,  24. 

Conjunctivitis,  syphilitic,  486. 

Contusions,  231. 

Depressants,  44. 
Diaphoretics,   45. 
Dislocations,  295. 
Diuretics,  46. 

Ear,  foreign  bodies  in,  361. 
Ectropium,  420. 
Elbow,  excision  of,  503. 
Emphysema,  353. 
Encanthus,  421. 
Encephaloid,  136. 
Enchondroma,  123. 


:  Entropium,  419. 
Epistaxis,  360. 
Epitheliomn,  127,  421,  431. 
Exostosis,  317  ;  syphilitic,  495. 
Eye,  diseases  of,  406. 

False  joint,  306. 

Female  generative  organs,  diseases  of, 

388. 

Fever,  34. 

Fistula  lachrymal!*,  421. 
Fistula,  perineal,  223. 
Foot,  injury  of,  505. 
Fractures,  269;  compound,  275. 
Fumigations,  mercurial,  493. 

Goitre,  346. 

Gonorrhoea,  213. 

Gummy  tumors,  syphilitic,  485. 

Gunshot  wounds,  240. 

Hemorrhage   from  inflammation,    83; 

arrest  of,  154 
Harelip,  100. 

Hernia,  186  ;  treatment  of,  190 
Hydatids,  121. 
Hydrophobia,  252. 

Impotence,  428. 

Inflammation,  29;  results  of,  65;  ter- 
minations of,  60  ;  treatment  of,  38. 
Iritis,  syphilitic,  486. 

Jaws,  diseases  of,  367. 
i  Joints,  wounds  of,  327  ;  movable  carti- 
lages in,  328. 

Keloid,  126. 

Lithotomy,  201. 
Lithotrity,  202. 
Lymphization,  69. 

Malformations,  98. 
Morbus  coxarius,  331. 
Muscles,  injuries  of,  337. 


508 


INDEX. 


Nsevus,  112. 

Necrosis,  syphilitic,  498. 
Nerves,  wounds  of,  380. 
Norfolk  itch,  441. 

Nose,  deformities  of,  432,  501  ;  diseases 
of,  363  ;  syphilis  in,  466. 

Onychia,  481. 

Ophthalmia,  406;   purulent,  410  ;    stru- 

mous,  408. 
Orchitis,  218. 
Ostitis,  syphilitic,  494. 
Ovaries,  "diseases  of,  398. 
Ovariotomy,  402. 

Periostitis,  syphilitic,  494. 

Podelcoma,  111. 

Pododynia,  111. 

Poisons,  249. 

Ptisanes,  antisyphilitic,  489. 

Rectum,  deficiency  of,  112  ;  examination 

of,  506. 
Rheumatism,  syphilitic,  482. 

Sarcocele,  syphilitic,  481. 
Scrofula,  141. 
Skin-grafting,  429. 
Softening,  93. 
Spermatorrhoea,  424. 
Spina  bifida,  380. 
Spine,  diseases  of,  319. 


Sprains,  322. 

Staphyloma,  413. 

Strabismus.  422. 

Stricture  of  urethra,  219. 

Suppuration,  76. 

Sympathy,   26. 

Syphilides,  471. 

Syphilis,  439  ;  iodide  of  potassium  in, 

452  ;  mercury  in,  448. 
Syphilis,  secondary,  462  ;  tertiary,  494. 

Teeth,  371. 

Tetanus,  236. 

Throat,  syphilis  in,   467  ;    wounds  of, 

340. 

Tongue,  diseases  of,  369. 
Tonsils,  369. 
Tracheotomy,  342. 
Transformation,  94. 
Tumors,  115;  semi-malignant,  122. 

Ulcers,  84. 

Uterus,  diseases  of,  388. 
Urine,  incontinence  of,  212  ;  retention 
of,  212. 

Veins,  dilatation  of,  172. 
Vesical  calculus,  198. 
Vesico-vaginal  fistula,  404. 

Wounds,  233. 
Wry-neck,  104. 


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valuable  articles,  with  special  reference  to  the  wants  of  the  AMERICAN  PRAC- 
TITIONER. 

The  work  is  now,  by  almost  universal  consent,  both  in  England  and  the  United  States, 
acknowledged  to  be  in  advance  of  all  other  works  on  The  Science  and  Practice  of  Medicine. 
It  is  a  most  thorough  and  complete  TEXT-BOOK  for  students  of  medicine,  following  such  a 
systematic  arrangement  as  will  give  them  a  consistent  view  of  the  main  facts,  doctrines,  and 
practice  of  medicine,  in  accordance  with  accurate  physiological  and  pathological  principles 
and  the  present  state  of  science.  For  the  practitioner  it  will  be  found  equally  acceptable  as 
a  work  of  reference. 

ALLINGHAM  (WILLIAM),  F.  R.  C.  S., 

Surgeon  to  St,  Mark's  Hospital  for  Fistula,  &c, 

FISTULA,  HEMORRHOIDS,  PAINFUL  ULCER,  STRICT- 
URE, PROLAPSUS,  and  other  Diseases  of  the  Rectum,  their  Diagnosis 
and  •  Treatment.  Second  Edition,  Revised  and  Enlarged  by  the 
Author.  Price  .........  $2.00 

This  book  has  been  well  received  by  the  Profession ;  the  first  edition  sold  rap- 
idly ;  the  present  one  has  been  revised  by  the  author,  and  some  additions  made 
chiefly  as  to  the  mode  of  treatment. 

The  Medical  Press  and  Circular,  speaking  of  it,  says :  "  No  book  on  this  special  subject 
can  at  all  approach  Mr.  Alliugham's  in  precision,  clearness,  and  practical  good  sense." 

The  London  Lancet :  "  As  a  practical  guide  to  the  treatment  of  afiections  of  the  lower 
bowel,  this  book  is  worthy  of  all  commendation." 

The  Edinburgh  Monthly :  "  We  cordially  recommend  it  as  well  deserving  the  careful  study 
of  Physicians  and  Surgeons." 


6 

ATTHILL  (LOMBE),  M.  D., 

Fellow  and  Examiner  in  Midwifery,  King  and  Queen's  College  of  Physicians,  Dublin, 

CLINICAL  LECTURES  ON  DISEASES  PECULIAR  TO  WO- 
MEN. Second  Edition,  Revised  and  Enlarged,  with  Six  Lithographic 
Plates  and  other  Illustrations  on  Wood.  Price  .  .  .  *  2.00 

The  value  and  popularity  of  this  book  is  proved  by  the  rapid  sale  of  the  first  edition, 
which  was  exhausted  in  less  than  a  year  from  the  time  of  its  publication.     It  appears  to 

fossess  three  great  merits  :  First,  It  treats  of  the  diseases  very  common  to  females.  Second, 
t  treats  of  them  in  a  thoroughly  clinical  and  practical  manner.  Third,  It  is  concise,  orig- 
inal, and  illustrated  by  numerous  cases  from  the  author's  own  experience.  His  style  is  clear 
and  the  volume  is  the  result  of  the  author's  large  and  accurate  clinical  observation  recorded 
in  a  remarkable,  perspicuous,  and  terse  manner,  and  is  conspicuous  for  the  best  qualities  of 
a  practical  guide  to  the  student  and  practitioner.  — British  Medical  Journal. 

ADAMS  (WILLIAM),  F.  R.  C.  S., 

Surgeon  to  the  Royal  Orthopedic  and  Great  Northern  Hospitals, 

CLUB-FOOT:  ITS  CAUSES,  PATHOLOGY,  AND  TREAT- 
MENT. Being  the  Jacksonian  Prize  Essay  of  the  Royal  College  of 
Surgeons.  A  New  Revised  and  Enlarged  Edition,  with  106  Illustrations 
engraved  on  Wood,  and  Six  Lithographic  Plates.  A  large  Octavo 
Volume.  Price *5-oo 


ADAMS  (ROBERT),  M.  D., 

Regius  Professor  of  Surgery  in  the  University  of  Dublin,  &c.,  dtc, 

RHEUMATIC  GOUT,  OR  CHRONIC  RHEUMATIC  ARTHRI- 
TIS OF  ALL  THE  JOINTS.  The  Second  Edition.  Illustrated  by 
numerous  Woodcuts,  and  a  quarto  Atlas  of  Plates.  2  Volumes. 
Price $8.50 

ALTHAUS  (JULIUS),  M.D., 

Physician  to  the  Infirmary  of  Epilepsy  and  Paralysis, 

A  TREATISE  ON  MEDICAL  ELECTRICITY,  Theoretical  and 
Practical,  and  its  Use  in  the  Treatment  of  Paralysis,  Neuralgia,  and  other 
Diseases.  Third  Edition,  Enlarged  and  Revised,  with-  One  Hundred 
and  Forty-six  Illustrations.  In  one  volume  octavo.  Price  .  $6.00 

In  this  work  both  the  scientific  and  practical  aspects  of  the  subject  are  ably,  concisely,  and 
thoroughly  treated.  It  is  much  the  best  work  treating  of  the  remedial  effects  of  electricity 
in  the  Euglish  language.  —  New  York  Medical  Record. 

ARNOTT  (HENRY),  F.R.C.S. 

CANCER:  its  Varieties,  their  Histology  and  Diagnosis.  \Yith  Five 
Lithographic  Plates  and  Twenty-two  Wood  Engravings.  Price  $2.25 

AGNEW  (D.  HAYES),  M.D., 

Professor  of  Surgery  in  the  University  of  Pennsylvania. 

THE  LACERATIONS  OF  THE  FEMALE  PERINEUM,  AND 
VESICO-VAGINAL  FISTULA,  their  History  and  Treatment,  with 
numerous  Illustrations.  Octavo.  Price  .  .  .  .  *  1.50 

Prof.  Agnew  has  been  a  most  indefatigable  laborer  in  this  department,  and  his  work  stands 
deservedly  high  in  the  estimation  of  tbe  profession.  It  is  well  illustrated,  and  full  descrip- 
tions of  the  operations  and  instruments  employed  are  given.  —  Canada  Lancet. 


ACTON  (WILLIAM),  M.R.C.S.,  ETC. 

THE  FUNCTIONS  AND  DISORDERS  OF  THE  REPRODUC- 
TIVE ORGANS.  In  Childhood,  Youth,  Adult  Age,  and  Advanced 
Life,  considered  in  their  Physiological,  Social,  and  Moral  Relations. 
Fourth  American  from  the  Fifth  London  Edition.  Carefully  revised  by 
the  Author,  with  additions.  .  .  .  .  .  .  .  *  2.50 

Mr.  Acton  has  done  good  service  to  society  by  grappling  manfully  with  sexual  vice,  and 
we  trust  that  others,  whose  position  as  men  of  science  and  teachers  enable  them  to  speak 
with  authority,  will  assist  in  combating  and  arresting  the  evils  which  it  entails.  The  spirit 
which  pervades  his  book  is  one  which  does  credit  equally  to  the  head  and  to  the  heart  of  the 
author.  —  British  and  Foreign  Medico- Chirurgical  Review. 

SAME  AUTHOR. 

PROSTITUTION:  Considered  in  its  Moral,  Social,  and  Sanitary  As- 
pects. Second  Edition,  Enlarged.  Price  .  .  .  .  $5.00 

ANSTIE  (FRANCIS  E.),  M.D., 

Lecturer  on  Materia  Medica  and  Therapeutics,  etc, 

STIMULANTS  AND  NARCOTICS.  Their  Mutual  Relations,  with 
Special  Researches  on  the  Action  of  Alcohol,  Ether,  and  Chloroform 
on  the  Vital  Organism.  Octavo.  .....  $3.00 

ANDERSON  (M'CALL),  M.D., 

Professor  of  Clinical  Medicine  in  the  University  of  Glasgow,  &c, 

ECZEMA.  The  Pathology  and  Treatment  of  the  various  Eczema- 
tous  Affections  or  Eruptions  of  the  Skin.  The  Third  Revised  and  En- 
larged Edition.  Octavo.  Price  .  .  .  .  .  .  $2.75 

BUZZARD  (THOMAS),  M.  D., 

Physician  to  the  National  Hospital  for  Paralysis  and  Epilepsy, 

CLINICAL  ASPECTS  OF   SYPHILITIC   NERVOUS  AFFEC- 
TIONS.    i2mo.     Cloth.     Price $1.75 

BASH  AM  (w.  R.),  M.D.,  F.R.C.P., 

Senior  Physician  to  the  Westminster  Hospital,  &c, 

AIDS  TO  THE  DIAGNOSIS  OF  DISEASES  OF  THE  KID- 
NEYS. With  Ten  large  Plates.  Sixty  Illustrations.  Price  .  $2.00 

SAME  AUTHOR. 

ON  DROPSY,  AND  ITS  CONNECTION  WITH  DISEASES  OF 
THE  KIDNEYS,  HEART,  LUNGS  AND  LIVER.  With  Sixteen 
Plates.  Third  Edition.  Octavo. $5-°o 

M.  BARTH  AND  M.  HENRI  ROGER. 

A  MANUAL   OF   AUSCULTATION  AND   PERCUSSION.    A 

new  Translation,  from  the  Sixth  French  Edition.     .         .         .     *  i.oo 

S.  M.  BRADLEY,  F.  R.  C.  S. 

Senior  Assistant  Surgeon  Manchester  Royal  Infirmary. 

A  MANUAL  OF  COMPARATIVE  ANATOMY  AND  PHYSI- 
OLOGY. With  60  Illustrations.  Third  Edition.  Price  ,  *  2.00 


8 

BE  ALE  (LIONEL  s.),  M.D. 

DISEASE  GERMS:  AND  ON  THE  TREATMENT  OF  DIS- 
EASES CAUSED  BY  THEM. 

PART      I.— SUPPOSED  NATURE  OF  DISEASE  GERMS. 
PART    II.  — REAL  NATURE  OF  DISEASE  GERMS. 
PART  III.— THE  DESTRUCTION  OF  DISEASE  GERMS. 

Second  Edition,  much  enlarged,  with  Twenty-eight  full-page  Plates, 
containing  117  Illustrations,  many  of  them  colored.  Demy  Octavo. 
Price *4.oo 

This  new  edition,  besides  including  the  contents  revised  and  enlarged  of  the  two  former 
editions  published  by  Dr.  Beale  on  Disease  Germs,  has  an  entirely  new  part  added  on  "  The 
Destruction  of  Disease  Germs." 

SAME  AUTHOR. 

BIOPLASM.  A  Contribution  to  the  Physiology  of  Life,  or  an  Intro- 
duction to  the  Study  of  Physiology  and  Medicine,  for  Students.  With 
Numerous  Illustrations.  Price  .  .  .  .  .  $3-°° 

This  volume  is  intended  as  a  TEXT-BOOK  for  Students  of  Physiology,  explaining  the  nature 
of  some  of  the  most  important  changes  which  are  characteristic  of  and  peculiar  to  living 
beings. 

PROTOPLASM,  OR  MATTER  AND  LIFE.  Third  Edition,  very 
much  Enlarged.  Nearly  350  pages.  Sixteen  Colored  Plates.  One 
volume.  Price  .........*  4.00 

PART  I.  DISSENTIENT.      PART  II.  DEMONSTRATIVE.     PART  III.  SUGGESTIVE. 

HOW  TO  WORK  WITH  THE  MICROSCOPE.  Fourth  Edition, 
containing  400  Illustrations,  many  of  them  colored.  Octavo.  Pr.ice 

This  work  is  a  complete  manual  of  microscopical  manipulation,  and  contains  a  full  descrip- 
tion of  many  new  processes  of  investigation,  witli  directions  for  examining  objects  under  the 
highest  powers,  and  for  taking  photographs  of  microscopic  objects. 

ON  KIDNEY  DISEASES,  URINARY  DEPOSITS,  AND  CAL- 
CULOUS  DISORDERS.  Including  the  Symptoms,  Diagnosis,  and 
Treatment  of  Urinary  Diseases.  With  full  Directions  for  the  Chemical 
and  Microscopical  Analysis  of  the  Urine  in  Health  and  Disease.  The 
Third  Edition.  Seventy  Plates,  415  figures,  copied  from  Nature. 
Octavo.  Price  .  .  .  .  .  .  .  .  .  $10.00 

THE  USE  OF  THE  MICROSCOPE  IN  PRACTICAL  MEDI- 
CINE. For  Students  and  Practitioners,  with  full  directions  for  exam- 
ining the  various  secretions,  &c.,  in  the  Microscope.  Fourth  Edition. 
500  Illustrations.  Octavo.  Preparing. 

BLOXAM  (c.  L.), 

Professor  of  Chemistry  in  King's  College,  London, 

CHEMISTRY,  INORGANIC  AND  ORGANIC.  With  Experi- 
ments and  a  Comparison  of  Equivalent  and  Molecular  Formulae.  With 
276  Engravings  on  Wood.  Second  Edition,  carefully  revised.  Octavo. 
Price,  in  cloth,  *  4.00;  leather,  .  .  .  .  .  .  *5-oo 

SAME  AUTHOR. 

LABORATORY  TEACHING;  OR  PROGRESSIVE  EXER- 
CISES IN  PRACTICAL  CHEMISTRY.  Third  Edition.  With 
Eighty-nine  Engravings.  Crown  Octavo.  Price  .  .  .  $2.00 


9 
BENNETT  (j.  HENRY),  M.  D. 

NUTRITION  IN  HEALTH  AND  DISEASE.  A  Contribution  to 
Hygiene  and  to  Clinical  Medicine.  Second  Edition,  Revised  and  En- 
larged. Octavo.  Cloth.  Price $2.50. 

BIRCH^sTT),  M.D., 

Member  cf  the  Royal  College  of  Physicians,  &c, 

CONSTIPATED  BOWELS ;  the  Various  Causes  and  the  Different 
Means  of  Cure.  Third  Edition.  Price  .  .  .  .  $1.00 

BUCKNILL  (JOHN  CHARLES),  M.D.,  &  TUKE  (DANIEL  H.),  M.D. 

A  MANUAL  OF  PSYCHOLOGICAL  MEDICINE:  containing  the 
Lunacy  Laws,  the  Nosology,  (Etiology,  Statistics,  Description,  Diagno- 
sis, Pathology  (including  Morbid  Histology),  and  Treatment  of  Insanity. 
Third  Edition,  much  enlarged,  with  Ten  Lithographic  Plates,  and  nu- 
merous other  Illustrations.  Octavo.  Price  .  .  .  .  $8.00 

This  edition  contains  upwards  of  200  pages  of  additional  matter,  and,  in  consequence  of 
recent  advances  in  Psychological  Medicine,  several  chapters  have  been  rewritten,  bringing 
the  Classification,  Pathology,  and  Treatment  of  Insanity  up  to  the  present  time. 

BROWNE  (j.  H.  BALFOUR),  ESQ. 

MEDICAL  JURISPRUDENCE  OF  INSANITY.  Second  Edition, 
very  much  Enlarged.  With  References  to  the  Scotch  and  American 
Decisions,  etc.,  etc.  Octavo.  Price $5.00 

BIDDLE  (JOHN  B.),  M.  D., 

Professor  of  Materia  Medicaand  Therapeutics  in  the  Jefferson  Medical  College,  Philadelphia,  &c, 

MATERIA  MEDICA,  FOR  THE  USE  OF  STUDENTS.     With 

Illustrations.     Seventh  Edition,  Revised  and  Enlarged.     Price     $4.00 

This  new  and  thoroughly  revised  edition  of  Professor  Biddle's  work  has  incorporated  in 

'-  just  issued.     It 
ler  this  head  as 
the  want 

of  an  elementary  work  on  the  subject.  The  larger  works  usually  recommended  as  text-books 
in  our  ^Medical  schools  are  too  voluminous  for  convenient  use.  This  will  be  found  to  contain, 
in  a  condensed  form,  all  that  is  most  valuable,  and  will  supply  students  with  a  reliable  guide 
to  the  course  of  lectures  on  Materia  Medica  as  delivered  at  the  various  Medical  schools  in 
the  United  States. 

BALFOUR^Tw.),  M.  D., 

Physician  to  the  Royal  Infirmary,  Edinburgh;  Lecturer  on  Clinical  Medicine,  &c. 

CLINICAL  LECTURES  ON  DISEASES  OF  THE  HEART  AND 
AORTA.  With  Illustrations.  Octavo.  Price  .  .  .  *  4.00 

BYFORD  (W.JH.),  A.M.,  M.D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  Chicago  Medical  Collesre,  &c, 

PRACTICE  OF  MEDICINE  AND  SURGERY.  Applied  to  the 
Diseases  and  Accidents  incident  to  Women.  Second  Edition,  Revised 
and  Enlarged.  Octavo.  Price,  cloth,  $5.00;  sheep  .  .  $6.00 

SAME  AUTHOR.  * 

ON  THE  CHRONIC  INFLAMMATION  AND  DISPLACEMENT 

OF  THE  UNIMPREGNATED  UTERUS.     A  New,  Enlarged,  and 

Thoroughly  Revised  Edition,  with  Numerous  Illustrations.   8vo.   *  2.50 

Dr.  Byford  writes  the  exact  present  state  of  medical  knowledge  on  the  subjects  presented; 

and  does  this  so  clearly,  so  concisely,  so  truthfully,  and  so  completely,  that  his  book  on  the 

lltp.riis  will    nlwnvs  mppt.    t.hp    nnnrvwnl   nf  flip    iirnfpcQinn     nnrl    KP    pvprvvvhprA    rpornrrlprl    fifi   A 


10 
BLACK  (D.  CAMPBELL),  M.  D., 

L.  R,  C,  S.  Edinburgh,  Member  of  the  General  Council  of  the  University  of  Glasgow,  &c.,  &c, 

THE  FUNCTIONAL  DISEASES  OF  THE  RENAL,  URINARY, 

and  Reproductive  Organs,  with  a  General  View  of  Urinary  Pathology. 

Price *  2.00 

The  style  of  the  author  is  clear,  easy,  and  agreeable,  .  .  .  his  work  is  a  valuable  contri- 
bution to  medical  science,  and  being  penned  in  that  disposition  of  unprejudiced  philosophical 
inquiry  which  should  always  guide  a  true  physician,  admirably  embodies  the  spirit  of  ita 
opening  quotation  from  Professor  Huxley.  —  Philada.  Med.  Times. 

BY  SAME  AUTHOR. 
LECTURES   ON   BRIGHT'S    DISEASE  OF  THE  KIDNEYS. 

Delivered  at  the  Royal  Infirmary  of  Glasgow.     With  20  Illustrations, 
engraved  on  Wood.     One  volume,  octavo,  in  Cloth.     Price     .    *  1.50 

BENTLEY  AND  TRIMEN'S 

MEDICINAL  PLANTS.  A  New  Illustrated  Work,  now  Publish- 
ing in  Monthly  Parts.  Twenty-one  Parts  now  ready.  Eight  Colored 
Plates  in  each  Part.  Price,  each, $2.00 

This  work  includes  full  botanical  descriptions,  and  an  account  of  the  properties  and  uses 
of  the  principal  plants  employed  in  medicine,  especial  attention  being  paid  to  those  which 
are  officinal  in  the  British  and  United  States  Pharmacopoeias.  The  plants  which  supply 
food  and  substances  required  by  the  sick  and  convalescent  will  be  also  included.  Each  spe- 
cies will  be  illustrated  by  a  colored  plate  drawn  from  nature. 

BEASLEY  (HENRY). 

THE  BOOK  OF  PRESCRIPTIONS.  Containing  over  3000 
Prescriptions,  collected  from  the  Practice  of  the  most  Eminent  Physi- 
cians and  Surgeons  —  English,  French,  and  American;  comprising  also 
a  Compendious  History  of  the  Materia  Medica,  Lists  of  the  Doses  of  all 
Officinal  and  Established  Preparations,  and  an  Index  of  Diseases  and 
their  Remedies.  Fifth  Edition,  Revised  and  Enlarged.  Price  *2-5o 

BY  SAME  AUTHOR. 

THE  POCKET  FORMULARY:  A  Synopsis  of  the  British  and 
Foreign  Pharmacopoeias.  Tenth  Revised  Edition.  Price  .  *2-5o 

THE  DRUGGIST'S  GENERAL  RECEIPT  BOOK  AND  VETERI- 
NARY FORMULARY.  Seventh  Edition.  Price.  ^2.50 

BRANSTON  (THOMAS  F.). 

HAND-BOOK  OF  PRACTICAL  RECEIPTS.  For  the  Chemist, 
Druggist,  &c. ;  with  a  Glossary  of  Medical  and  Chemical  Terms.  $1.50 

BRAUNE— BELLAMY. 

AN  ATLAS  OF  TOPOGRAPHICAL  ANATOMY.  After  Plane 
Sections  of  Frozen  Bodies,  containing  Thirty-four  Full-page  Photo- 
graphic Plates  and  numerous  other  Illustrations  on  Wood.  By  WILHELM 
BRAUNE,  Professor  of  Anatomy  in  the  University  of  Leipzig.  Trans- 
lated and  Edited  by  EDWARD  BELLAMY,  F.  R.  C.  S.,  Senior  Assistant  Sur- 
geon to,  and  Lecturer  on  Anatomy  and  Teacher  of  Operative  Surgery 
at,  the  Charing  Cross  Hospital,  London.  A  large  quarto  volume. 
Price  in  cloth,  $12.00  ;  half  morocco,  .....  $14.00 


11 
COHEN  (i.  SOLIS),  M.D. 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  Jefferson  Medical  College, 

ON  INHALATION.     ITS  THERAPEUTICS  AND  PRACTICE. 

Including  a  Description  of  the  Apparatus  employed,  &c.     With  Cases 
and  Illustrations.     A  New  Enlarged  Edition.     Price        .         .     $2.75 

SAME  AUTHOR. 
CROUP.     In  its  Relations  to  Tracheotomy.     Price         .         .    $1.00 

CARSON  (JOSEPH),  M.D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University, 

A  HISTORY  OF  THE  MEDICAL  DEPARTMENT  OF  THE 
UNIVERSITY  OF  PENNSYLVANIA,  from  its  Foundation  in  1765: 
with  Sketches  of  Deceased  Professors,  &c *  2.00 

CHARTERIS  (MATHE^),  M.  D., 

Member  of  Hospital  Staff  and  Professor  in  University  of  Glasgow. 

STUDENTS'  TEXT-BOOK  OF  THE  PRACTICE  OF  MEDI- 
CINE. With  Illustrations.  In  the  Press. 

This  book  will  form  one  volume  of  the  Students'  Guide  Series,  or  Text- Books,  now  in 
course  of  publication. 

CARPENTER  (w.  B.),  M.D.,  F.R.S. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.  The  Fifth 
London  Edition,  Revised  and  Enlarged,  with  more  than  500  Illustra- 
tions. .  $5-5° 

SAME  AUTHOR. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY.  The  Eighth  Revised 
and  Enlarged  Edition.  With  nearly  400  Illustrations  on  Steel  and 
Wood.  Edited  by  Mr.  HENRY  POWER.  1200  pages.  Octavo.  *5-5o 

CHAVASSE  (P.  HENRY),  F.R.C.S., 

Author  of  Advice  to  a  Wife,  Advice  to  a  Mother,  &c, 

APHORISMS  ON   THE    MENTAL   CULTURE  AND  TRAIN- 
ING OF  A  CHILD,  and  on  various  other  subjects  relating  to  Health 
and  Happiness.     Addressed  to  Parents.     Price         .         .         .     *i.oo 
Dr.  Chayasse's  works  have  been  very  favorably  received  and  had  a  large  circulation,  the 
value  of  his  advice  to  WIVES  and  MOTHERS  having  thus  been  very  generally  recognized. 
This  book  is  a  sequel  or  companion  to  them,  and  it  will  be  found  both  valuable  and  important 
to  all  who  have  the  care  of  families,  and  who  want  to  bring  up  their  children  to  become  useful 
men  and  women.     It  is  full  of  fresh  thoughts  and  graceful  illustrations. 

CLARKE  (W.FAIRLIE),  M.D., 

Assistant  Surgeon  to  Charing  Cross  Hospital. 

CLARKE'S  TREATISE  ON  DISEASES   OF  THE  TONGUE. 

With  Lithographic  and  Wood-cut  Illustrations.     Octavo.     Price  $5.00 

Minute  Exam- 
Inflammation, 
&c.,  &c. 

COOPER  (s.). 

A  DICTIONARY  OF  PRACTICAL  SURGERY  AND  ENCY- 
CLOPEDIA OF  SURGICAL  SCIENCE.  New  Edition,  brought 
down  to  the  present  time.  By  SAMUEL  A.  LANE,  F.R.C.S.,  assisted  by 
other  eminent  Surgeons.  In  two  vols. ,  of  over  i  ooo  pages  each.  $  1 5 .  oo 


12 
CLAY  (CHARLES),  M.  D. 

Fellow  of  the  London  Obstetrical  Society,  &c, 

THE  COMPLETE  HAND-BOOK  OF  OBSTETRIC  SURGERY, 

or,  Short  Rules  of  Practice  in  Every  Emergency,  from  the  Simplest  to 
the  most  Formidable  Operations  in  the  Practice  of  Surgery.  First 
American  from  the  Third  London  Edition.  With  numerous  Illustra- 
tions. In  one  volume.  *  2.00 

CHAMBERS~C^MAS  K.),  M.  D., 

LECTURES,  CHIEFLY  CLINICAL.  Illustrative  of  a  Restorative 
System  of  Medicine. 

CORMACK  (SIR  JOHN  ROSE^K,  B.,  F.  R.  S.  E.,  M.  D. 

Edinburgh  and  Paris,  Fellow  Royal  College  of  Physicians,  Physician  to  the  Hertford  British  Hospital,  Paris,  &c, 

CLINICAL  STUDIES,  Illustrated  by  Cases  observed  in  Hospital  and 
Private  Practice.  With  Illustrative  Plates.  2  Volumes.  Octavo.  *  5.00 

COBBOLD  (T.  SPENCER),  M.D.,  F.R.S. 

WORMS:  a  Series  of  Lectures  delivered  at  the  Middlesex  Hospital 
on  Practical  Helminthology.  Post  Octavo.  .  .  .  $2.00 

CLEAVELAND  (c.  H.),  M.D., 

Member  of  the  American  Medical  Association,  &c, 

A  PRONOUNCING  MEDICAL  LEXICON.    Containing  the  Cor- 
rect Pronunciation  and  Definition  of  Terms  used  in  Medicine  and  the 
Collateral  Sciences.     Improved  Edition,  Cloth,    *i.oo;  Tucks,  *  1.25 
This  work  is  not  only  a  Lexicon  of  all  the  words  in  common  use  in  Medicine,  but  it  is 
also  a  Pronouncing  Dictionary,  a  feature  of  great  value  to  Medical  Students.    To  the  Dis- 
penser it  will  prove  an  excellent  aid,  and  also  to  the  Pharmaceutical  Student.    It  has  received 
strong  commendation  both  from  the  Medical  Press  and  from  the  profession. 

COLES  (OAKLEY),  D.D.S. 

Dental  Surgeon  to  the  Hospital  for  Diseases  of  the  Throat,  die, 

A  MANUAL  OF  DENTAL  MECHANICS.  Containing  much 
information  of  a  Practical  Nature  for  Practitioners  and  Students. 

INCLUDING 

The  Preparation  of  the  Mouth  for  Artificial  Teeth,  on  Taking  Impressions,  Various 
Modes  of  Applying  Heat  in  the  Laboratory,  Casting  in  Plaster  of  Paris  and  Metal, 
Precious  Metals  used  in  Dentistry,  Making  Gold  Plates,  Various  Forms  of  Porcelain 
used  in  Mechanical  Dentistry,  Pivot  Teeth,  Choosing  and  Adjusting  Mineral  Teeth,  the 
Vulcanite  Base,  the  Celluloid  Base,  Treatment  of  Deformities  of  the  Mouth,  Receipts 
for  Making  Gold  Plate  and  Solder,  etc.,  etc. 
With  140  Illustrations.  Price  .  .  .  .  .  .  *  2.00 

SAME  AUTHOR. 

ON  DEFORMITIES  OF  THE  MOUTH,  CONGENITAL  AND 
ACQUIRED,  with  their  Mechanical  Treatment.  Second  Edition,  Re- 
vised and  Enlarged.  With  Illustrations.  Price,  .  .  .  $2.50 

CURLING  (T.B.),  F.R.S. 

Consulting  Surgeon  to  London  Hospital,  &Ci 

OBSERVATIONS  ON  DISEASES  OF  THE   RECTUM.     With 

Illustrations.  Fourth  Edition,  Revised  and  Enlarged.  Octavo.  Cloth. 
Price  ...........  $2.75 


13 

CLARK  (F.  LE  GROS),  F.  R.  S., 

Senior  Surgeon  to  St.  Thomas's  Hospital, 

OUTLINES  OF  SURGERY  AND  SURGICAL   PATHOLOGY, 

including  the  Diagnosis  and  Treatment  of  Obscure  and  Urgent  Cases, 
and  the  Surgical  Anatomy  of  some  Important  Structures  and  Regions. 
Assisted  by  W.  W.  WAGSTAFFE,  F.  R.  C.  S.,  Resident  Assistant-Surgeon 
of,  and  Joint  Lecturer  on  Anatomy  at,  St.  Thomas's  Hospital.  Second 
Edition,  Revised  and  Enlarged.  Price  ....  *3.oo 

COTTLE  (E.  WYJ?DHAM),}M.  A...  F.  R.  C.  S.,  &c. 

THE  HAIR  IN  HEALTH  AND  DISEASE.  Partly  from  Notes 
by  the  late  GEORGE  NAYLER,  F.  R.  C.  S.,  Surgeon  to  the  Hospital  for 
Diseases  of  the  Skin,  &c.  i8mo.  Cloth.  Price  .  .  $0.75 

COOLEY   (A.  jr.). 

CYCLOPAEDIA  OF  PRACTICAL  RECEIPTS.  Containing  Pro- 
cesses and  Collateral  Information  in  the  Arts,  Manufactures,  Profes- 
sions, and  Trades,  including  Medicine,  Pharmacy,  and  Domestic 
Economy ;  designed  as  a  General  Book  of  Reference  for  the  Mantfac- 
turer,  Tradesman,  Amateur,  and  Heads  of  Families.  The  Fifth  Edi- 
tion, Revised  and  partly  Rewritten  by  RICHARD  V.  TUSON,  F.C.S.,  &c. 
Over  1000  royal-octavo  pages,  double  columns.  With  Illustrations. 
Price *io.oo 

Every  part  of  this  edition  has  been  subjected  to  a  thorough  and  complete  revision  by  the 
editor,  assisted  by  other  scientific  gentlemen.  In  the  chemical  portion  of  the  book,  every 
subject  of  practical  importance  has  been  retained,  corrected,  and  added  to ;  to  the  name  of 
every  substance  of  established  composition  a  formula  has  been  attached ;  while  to  the  Phar- 
maceutist its  value  has  been  greatly  increased  by  the  additions  which  have  been  made  from 
the  British,  Indian,  and  United  States  Pharmacopoeias. 

CAZEAUX  (P.),  M.  D., 

Adjunct  Professor  of  the  Faculty  of  Medicine,  Paris,  etc, 

A  THEORETICAL  AND  PRACTICAL  TREATISE  ON  MIDWIFERY, 
including  the  Diseases  of  Pregnancy  and  Parturition.     Translated  from 
the  Seventh  French  Edition,  Revised,  Greatly  Enlarged,  and  Improved, 
by  S.  TARNIER,  Clinical  Chief  of  the  Lying-in  Hospital,  Paris,  etc., 
with  numerous  Lithographic  and  other  Illustrations.     Price,  in  Cloth, 
*6.oo;   in  Leather         ........     *  7«oo 

M.  Cazeaux's  Great  Work  on  Obstetrics  has  become  classical  in  its  character,  and  almost 
an  Encyclopaedia  in  its  fulness.  Written  expressly  for  the  use  of  students  of  medicine,  its 
teachings  are  plain  and  explicit,  presenting  a  condensed  summary  of  the  leading  principles 
established  by  the  masters  of  the  obstetric  art,  and  such  clear,  practical  directions  for  the 
management  of  the  pregnant,  parturient,  and  puerperal  states,  as  have  been  sanctioned  by 
the  most  authoritative  practitioners,  and  confirmed  by  the  author's  own  experience. 

DOBELL  (HORACE),  M.  D., 

Senior  Physician  to  the  Hospital, 

WINTER  COUGH  (CATARRH,  BRONCHITIS,  EMPHYSEMA, 
ASTHMA).  Lectures  Delivered  at  the  Royal  Hospital  for  Diseases  of  the 
Chest.     The  Third  Enlarged  Edition,  with  Colored  Plates.     Octavo. 
Price          ..........*  3.00 

This  work  has  been  thoroughly  revised.  Two  new  Lectures  have  been  added  —  viz., 
Lecture  IV.,  "On  the  Natural  Course  of  Neglected  Winter  Cough,  and  on  the  Interdepen- 
dence of  Winter  Cough  with  other  Diseases  ;  "  Lecture  IX.,  "  On  Change  of  Climate  in  Winter 
Cough."  Also  additional  matter  on  Post-nasal  Catarrh,  Ear-Cough,  Artificial  Respiration  as 
a  means  of  Treatment,  Laryngoscopy,  New  Methods  and  Instruments  in  Treating  of  Emphy-- 
sema,  a  good  Index,  and  Colored  Plates,  with  appended  Diagnostic  Physical  signs. 


14 
DIXON  (JAMES),  F.  R.  C  S. 

Surgeon  to  the  Royal  London  Ophthaimic  Hospital,  &c, 

A  GUIDE  TO  THE  PRACTICAL  STUDY  OF  DISEASES  OF 
THE  EYE,  with  an  Outline  of  their  Medical  and  Operative  Treatment, 
with  Test  Types  and  Illustrations.  Third  Edition,  thoroughly  Revised, 

and  a  great  portion  Rewritten.  Price *  2.00 

Mr.  Dixon's  book  is  essentially  a  practical  one,  written  by  an  observant  author,  who  brings 

to  his  special  subject  a  sound  knowledge  of  general  Medicine  and  Surgery. — Dublin  Quarterly. 

DILLNBERGER  (DR.  EMIL). 

A  HANDY-BOOK  OF  THE  TREATMENT  OF  WOMEN  AND 
CHILDREN'S  DISEASES,  according  to  the  Vienna. Medical  School. 
Part  I.  The  Diseases  of  Women.  Part  II.  The  Diseases  of  Children. 
Translated  from  the  Second  German  Edition,  by  P.  NICOL,  M.  D. 
Price  .  .  .  .  .  .  .  .  .  .  *  1.50 

Many  practitioners  will  be  glad  to  possess  this  little  manual,  which  gives  a  large  mass 
of  practical  hints  on  the  treatment  of  diseases  which  probably  make  up  the  larger  half  of 
every-day  practice.  The  translation  is  well  made,  and  explanations  of  reference  to  German 
medicinal  preparations  are  given  with  proper  fulness.  —  The  Practitioner. 

DUNGLISON  (RICHARD  j.),  M.  D. 

THE  PRACTITIONER'S  REFERENCE  BOOK.  Containing 
Therapeutic  and  Practical  Hints,  Dietetic  Rules  and  Precepts, '  and 
other  General  Information  Useful  to  the  Physician,  Pharmacist,  and 
Student.  Octavo.  Cloth.  Price $3-5° 

DUCHENNE  (DR.  G.  B.). 

LOCALIZED    ELECTRIZATION    AND    ITS    APPLICATION 
TO  PATHOLOGY  AND    THERAPEUTICS.     Translated  by  HER- 
BERT TIBBITS,  M.D.     With  Ninety-two  Illustrations.     Price     .     $3.00 
Duchenne's  great  work  is  not  only  a  well-nigh  exhaustive  treatise  on  the  medical  uses  of 
Electricity,  but  it  is  also  an  elaborate  exposition  of  the  different  diseases  in  which  Electric- 
ity has  proved  to  be  of  value  as  a  therapeutic  and  diagnostic  agent. 

PART  II.,  illustrated  by  chromo-l.rthographs  and  numerous  wood-cuts,  is  preparing. 

DURKEE  (SILAS),  M.D., 

Fellow  of  the  Massachusetts  Medical  Society,  &c, 

GONORRHOEA  AND  SYPHILIS.  The  Fifth  Edition,  Revised 
and  Enlarged,  with  Portraits  and  Eight  Colored  Illustrations.  Octavo. 
Price  .  .  .  .  .  .  .  .  .  .  .  *3-5o 

Dr.  Durkee's  work  impresses  the  reader  in  favor  of  the  author  by  its  general  tone,  the 
thorough  honesty  everywhere  evinced,  the  skill  with  which  the  book  is  arranged,  the  man- 
ner in  which  the  facts  are  cited,  the  clever  way  in  which  the  author's  experience  is  brought 
in,  the  lucidity  of  the  reasoning,  and  the  care' with  which  the  therapeutics  of  venereal  com- 
plaints are  treated. — Lancet. 

DRUITT  (ROBERT),  F.R.C.S. 

THE  SURGEON'S  VADE-MECUM.  A  Manual  of  Modern  Sur- 
gery. The  Tenth  Revised  and  Enlarged  Edition,  with  350  Illustra- 
tions.    $5-oo 


15 
DALBY  (w.  B.),  F.  R.  C.  S., 

Aural  Surgeon  to  St.  George's  Hospital. 

LECTURES  ON  THE  DISEASES  AND  INJURIES  OF  THE 
EAR.  Delivered  at  St.  George's  Hospital.  With  Illustrations. 
Price $I-5° 

We  cordially  recommend  this  admirable  volume  by  Mr.  Dalby  as  a  trustworthy  guide  in 
the  treatment  of  the  affections  of  the  ear.  The  book  is  moderate  in  price,  beautifully  illus- 
trated by  wood-cuts,  and  got  up  in  the  best  style.  —  Glasgow  Medical  Journal. 

DAY  (WILLIAM  HENRY),  M.  D., 

Physician  to  the  Samaritan  Hospital  for  Women  and  Children,  &c, 

HEADACHES,  THEIR  NATURE,  CAUSES,  AND  TREAT- 
MENT. i2mo.  Cloth.  Price $2.00 

DUNGLISON  (ROBLEY),  M.  D., 

Late  Professor  of  Institutes  of  Medicine,  &.C.,  in  the  Jefferson  Medical  College. 

A  HISTORY  OF  MEDICINE,  from  the  Earliest  Ages  to  the  Com- 
mencement of  the  Nineteenth  Century.  Edited  by  his  son,  RICHARD 
J.  DUNGLISON,  M.  D.  .  .  .  .  .  $2.50 

ELLIS  (EDWARD),  M.  D., 

Physician  to  the  Victoria  Hospital  for  Sick  Children,  &c, 

A  PRACTICAL   MANUAL   OF   THE   DISEASES   OF  CHIL- 
DREN,  with  a  Formulary.       Third  Enlarged   Edition,  Revised  and 
Improved.     One  volume. 
The  AUTHOR,  in  issuing  this  new  edition  of  his  book,  says :  "T.  have  very  carefully  revised 

each  chapter,  adding  several  new  sections,  and  making  considerable  additions  where  the 

subjects  seemed  to   require  fuller  treatment,  without,  however,  sacrificing  conciseness  or 

unduly  increasing  the  bulk  of  the  volume." 

ELAM  (CHARLES),  M.D.,  F.R.C.P. 

ON  CEREBRIA  AND  OTHER  DISEASES  OF  THE  BRAIN. 
Octavo. $2.50 

FOTHERGILL  (j.  MILNER),  M.  D. 

THE  HEART  AND  ITS  DISEASES,  AND  THEIR  TREAT- 
MENT. With  Illustrations.  Octavo.  Price  .  .  .  $5.00 

DIGITALIS.  Its  Mode  of  Action  and  its  Use,  illustrating  the 
Effect  of  Remedial  Agents  over  Diseased  Conditions  of  the  Heart. 
Price 1 1. 25 


FOX  (TILBURY),  M.  D.,  F.  R.  C.  P. 

Physician  to  the  Department  for  Skin  Diseases  in  University  College  Hospital, 

ATLAS  OF  SKIN  DISEASES.  Consisting  of  a  Series  of  Colored 
Illustrations,  in  Monthly  Parts,  together  with  Descriptive  Text  and 
Notes  upon  Treatment ;  each  Part  containing  Four  Plates,  reproduced  by 
Chromo-Lithography  from  the  work  of  Willan  &  Bateman,  or  taken  from 
Original  Sources.  Now  Complete  in  18  Parts.  Price,  per  Part,  $2.00  ; 
or  in  one  laige  Folio  volume,  bound  in  cloth.  Price  .  .  $36.00 


16 

FENNER  (c.  s.),  M.  D.,  &c. 

VISION:  ITS  OPTICAL  DEFECTS,  and  the  Adaptation  of  Spec- 
tacles; embracing  Physical  Optics,  Physiological  Optics,  Errors  of  Re- 
fraction and  Defects  of  Accommodation,  or  Optical  Defects  of  the  Eye. 
With  74  Illustrations.  Selections  from  the  Test  Types  of  Jaeger  and 
Snellen,  etc.  Octavo.  Price  ......  $3.50 

FOSTER  (BALTHAZAR),  M,  D., 

Professor  of  Medicine  in  Queen's  College, 

LECTURES  AND  ESSAYS  ON  CLINICAL  MEDICINE.  Re- 
vised and  Enlarged  by  the  Author.  With  Engravings.  Octavo. 
Price  .  .  .  .  .  .  .  .  .  .  .  *3-oo 

FRANKLAND  (E.),  M.  D.,  F.  R.  S.,  &c. 

HOW  TO  TEACH  CHEMISTRY,  being  the  substance  of  Six 
Lectures  to  Science  Teachers.  Reported,  with  the  Author's  sanction, 
by  G.  George  Chaloner,  F.  C.  S.,  &c.  With  Illustrations  .  $1.25 

FEN  WICK  (SAMUEL),  M.D.,  F.R.C.P. 

THE  MORBID  STATES  OF  THE  STOMACH  AND  DUO- 
DENUM, AND  THEIR  RELATIONS  TO  THE  DISEASES  OF 
OTHER  ORGANS.  With  Ten  Plates $5.00 

FLINT  (AUSTIN),  M.D., 

Professor  of  the  Principles  and  Practice  of  Medicine,  &c.,  Bellevue  Hospital  College,  New  York, 

CLINICAL  REPORTS  ON  CONTINUED  FEVER.  Based  on 
an  Analysis  of  One  Hundred  and  Sixty-four  Cases,  with  Remarks  on 
the  Management  of  Continued  Fever;  the  Identity  of  Typhus  and 
Typhoid  Fever;  Diagnosis,  &c.,  &c.  Octavo.  Price  .  .  $2.00 

GANT  (FREDERICK  j.),  F.  R.  C.  S., 

Surgeon  to  the  Royal  Free  Hospital,  &c, 

DISEASES  OF  THE  BLADDER,  PROSTATE  GLAND,  AND 
URETHRA,  including  a  Practical  View  of  Urinary  Diseases,  Deposits, 
and  Calculi.  Fourth  Edition,  Revised  and  Enlarged.  With  New  Il- 
lustrations. Now  Ready.  Price  .  .  .  .  .  •  *3-5° 

The  fact  that  a  fourth  edition  of  this  book  has  been  required  seems  to  be  sufficient  proof 
of  its  value.  The  author  has  carefully  revised  and  added  such  additional  matter  as  to  make 
it  more  complete  and  practically  useful. 

GODFREY  (BENJAMIN),  M.D.,  F.R.A.S. 

THE  DISEASES  OF  HAIR:  a  Popular  Treatise  upon  the  Affec- 
tions of  the  Hair  System.  ..'...  .  $1.5° 

GROSS  (SAMUEL  D.),  M.D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  &c, 

AMERICAN  MEDICAL  BIOGRAPHY  OF  THE  NINETEENTH 
CENTURY.  With  a  Portrait  of  BENJAMIN  RUSH,  M.D.  Octavo.  $3.50 


17 
GREENHOW  (E.  HEADLAM),  M.D., 

Fellow  of  the  Royal  College  of  Physicians,  &c. 

ON  CHRONIC  BRONCHITIS,  Especially  as  Connected  with  Gout, 

Emphysema,  and  Diseases  of  the  Heart.     Price       .         .         .     *i-5o 

Of  all  works  yet  written  on  Chronic  Bronchitis,  this  is  undoubtedly  the  best.     The  style 

is  clear  and  to  the  point,  and  the  principles  of  pathology  and  treatment  eminently  correct 

and  practical.    It  is  a  positive  addition  to  our  medical  literature.  —  Journal  Psychological 

Medicine. 

BY  SAME  AUTHOR. 

ADDISON'S  DISEASE.  Being  the  Cronian  Lectures  for  1875. 
Delivered  before  the  Royal  College  of  Physicians.  Revised,  and  Illus- 
trated by  numerous  Cases  and  5  full-page  Colored  Engravings.  One 
volume,  octavo.  Price  . *  3.00 


HARLEY  (GEORGE),  M.  D.,  F.  R.  C.  P., 

Physician  to  University  College  Hospital. 

THE  URINE  AND  ITS  DERANGEMENTS:  With  the  Applica- 
tion of  Physiological  Chemistry  to  the  Diagnosis  and  Treatment  of 
Constitutional  as  well  as  Local  Diseases.  New  Revised  and  Enlarged 
Edition  preparing.  With  Engravings. 

•\Ve  have  here  a  valuable  addition  to  the  library  of  the  practising  physician; 
not  only  for  the  information  which  it  contains,  but  also  for  the  suggestive  way  in  which 
many  of  the  subjects  are  treated,  as  well  as  for  the  fact  that  it  contains  the  ideas  of  one  who 
thoroughly  believes  in  the  future  capabilities  of  Therapeutics  based  on  Physiological  facts, 
and  in  the  important  service  to  be  rendered  by  Chemistry  to  Physiological  investigation. 

American  Journal  of  the  Medical  Science. 

HEATH   (CHRISTOPHER),  F.  R.  C.  S., 

Surgeon  to  University  College  Hospital  and  Holme  Professor  of  Clinical  Surgery  in  University  College. 

OPERATIVE  SURGERY.  Elegantly  Illustrated  by  20  Large  Col- 
ored Plates,  Imperial  Quarto  Size,  each  Plate  containing  several  Fig- 
ures, drawn  from  Nature  by  M.  Leveille,  of  Paris,  and  Colored  by  hand 
under  his  direction.  Complete  in  Five  Quarterly  Parts.  Price,  per  Part, 
$2.50;  or  in  one  volume,  handsomely  bound  in  cloth.  Price  $14.00 

HEWITT  (GRAILY),  M.  D., 

Physician  to  the  British  Lying-in  Hospital,  and  Lecturer  on  Diseases  of  Women  and  Children,  &c. 

THE  DIAGNOSIS,  PATHOLOGY,  AND  TREATMENT  OF 
DISEASES  OF  WOMEN,  including  the  Diagnosis  of  Pregnancy. 
Founded  on  a  Course  of  Lectures  delivered  at  St.  Mary's  Hospital 
Medical  School.  The  Third  Edition,  Revised  and  Enlarged,  with 
new  Illustrations.  Octavo.  Price  in  Cloth  .  .  .  *  4.00 

"         Leather     .         .         .        *5-oo 

This  new  edition  of  Dr.  Hewitt's  book  has  been  so  much  modified,  that  it  may  be  considered 
substantially  a  new  book ;  very  much  of  the  matter  has  been  entirely  rewritten,  and  the  whole 
work  has  been  rearranged  in  such  a  manner  as  to  present  a  most  decided  improvement  over 
previous  editions.  Dr.  Hewitt  is  the  leading  clinical  teacher  on  Diseases  of  Women  in  London, 
and  the  characteristic  attention  paid  to  Diagnosis  by  him  has  given  his  work  great  popularity 
there.  It  may  unquestionably  be  considered  the  most  valuable  guide  to  correct  Diagnosis  to 
be  found  in  the  English  language.  o 


18 
HILLIER  (THOMAS),  M.D., 

Physician  to  the  Hospital  for  Sick  Children,  &c, 

A  CLINICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Octavo.     Price      .         .         .         .         .         .         .         .          .     *  2.00 

We  have  said  enough  to  indicate  and  illustrate  the  excellence  of  Dr.  Hillier's  volume.  It 
is  eminently  the  kind  of  book  needed  by  all  medical  men  who  wish  to  cultivate  clinical 
accuracy  aud  sound  practice.  —  London  Lancet. 

HOLDEN  (LUTHER),  F.R.C.S. 

HUMAN  OSTEOLOGY,  comprising  a  Description  of  the  Bones 
with  Delineations  of  the  Attachments  of  the  Muscles,  &c.  With 
numerous  Illustrations.  Fifth  Edition,  carefully  Revised.  Price,  $6.00 

HOLDEN'S  MANUAL  OF  DISSECTIONS.     Price         .        $5.00 
HARRIS  (CHAPIN  A.),  M.  D.,  D.  D.  S. 

Late  President  of  and  Professor  of  the  Principles  and  Practice  of  Dental  Surgery  in  the  Baltimore  College,  &.c, 

THE  PRINCIPLES  AND  PRACTICE  OF  DENTISTRY.  Tenth 
Revised  Edition.  In  great  part  rewritten,  rearranged,  and  with  many 
new  and  important  Illustrations.'  Including — i.  Dental  Anatomy  and 
Physiology.  2.  Dental  Pathology  and  Therapeutics.  3.  Dental  Sur- 
gery. 4.  Dental  Mechanics.  Edited  by  P.  H.  AUSTEN,  M.D.,  Pro- 
fessor of  Dental  Science  and  Mechanism  in  the  Baltimore  College  of 
Dental  Surgery.  With  nearly  400  Illustrations,  including  many  new 
ones  made  especially  for  this  edition.  Royal  octavo.  Price,  in  cloth, 
$6.50;  in  leather $7.50 

This  new  edition  of  Dr.  Harris's  work  has  been  thoroughly  revised  in  all  its  parts  —  more 
so  than  any  previous  edition.  So  great  have  been  the  advances  in  many  branches  of  dentistry, 
that  it  was  found  necessary  to  rewrite  the  articles  or  subjects,  and  this  has  been  done  in  the 
most  efficient  manner  by  Professor  Austen,  for  many  years  an  associate  and  friend  of  Dr. 
Harris,  assisted  by  Professor  Gorgas  and  Thomas  S.  Latimer,  M.  D.  The  publishers  feel 
assured  that  it  will  now  be  found  the  most  complete  text-book  for  the  student  and  guide  for 
the  practitioner  in  the  English  language. 

SAME  AUTHOR. 

A  DICTIONARY  OF  MEDICAL  TERMINOLOGY,  DENTAL 
SURGERY,  AND  THE  COLLATERAL  SCIENCES.  Fourth  Edition, 
Carefully  Revised  and  Enlarged,  by  FERDINAND  J.  S.  GORGAS,  M.  D., 
D.D.S.,  Professor  of  Dental  Surgery  in  the  Baltimore  College,  &c.,  &c. 
Royal  octavo.     Price,  in  cloth,  $6.50;  in  leather          .         .         $7.50 
The  many  advances  in  Dental  Science  rendered  it  necessary  that  this  edition  should  be 
thoroughly  revised,  which  has  been  done  in  the  most  satisfactory  manner  by  Professor  Gorgas, 
Dr.  Harris's  successor  in  the  Baltimore  Dental  College,  he  having  added  nearly  three  thou- 
sand new  words;,  besides  making  many  additions  and  corrections.     The  doses  of  the  more 
prominent  medicinal  agents  have  also  been  added,  and  in  every  way  the  book  has  been  greatly 
improved,  and  its  value  enhanced  as  a  work  of  reference. 

HANDY  (WASHINGTON  R.),  M.D. 

Late  Professor  of  Anatomy,  &c,,  in  the  Baltimore  College, 

A  TEXT-BOOK  OF  ANATOMY,  AND  GUIDE  TO  DISSEC- 
TIONS. For  the  Use  of  Students  of  Medicine  and  Dental  Surgery. 
With  312  Illustrations.  Octavo.  Price  ....  *3-oo 

Dr.  Handy's  work  was  prepared  with  special  reference  to  the  wants  of  the  Student  and 

Practitioner  of  Dental  Surgery.     Directing  particular  attention  to  the  Mouth,  it  shows  step 

by  step  the  important  Anatomical  and  Phvsiological  relations  which  it  has  with  each  and 

all  the  organs  and  functions  of  the  general  system. 


19 

HARDWICH  AND  DAWSON. 

HARDWICH'S  MANUAL  OF  PHOTOGRAPHIC  CHEMISTRY. 

With  Engravings.      Eighth  Edition.     Edited   and  Rearranged  by  G. 
DAWSON,  Lecturer  on  Photography,  &c.,  &c.      121110.       .         .     $2.00 

The  object  of  the  Editor  has  been  to  give  practical  instruction  in  this  fascinating  art,  and 
to  lead  the  novice  from  first  principles  to  the  higher  branches,  impressing  him  with  the  value 
of  care  and  exactness  in  every  operation. 

HEADLAND  (F.  w.),  M.  D., 

Fellow  of  the  Royal  College  of  Physicians,  &c.,  &c, 

ON  THE  ACTION  OF  MEDICINES  IN  THE  SYSTEM.  Sixth 
American  from  the  Fourth  London  Edition.  Revised  and  Enlarged. 
Octavo.  Price  .........  $3.00 

Dr.  Headland's  work  gives  the  only  scientific  and  satisfactory  view  of  the  action  of  medi- 
cine; and  this  not  in  the  way  of  idle  speculation,  but  by  demonstration  and  experiments, 
and  inferences  almost  as  indisputable  as  demonstrations.  It  is  truly  a  great  scientific  work 
in  a  small  compass,  and  deserves  to  be  the  hand-book  of  every  lover  of  the  Profession.  It 
has  received  the  approbation  of  the  Medical  Press,  both  in  this  country  and  in  Europe,  and 
is  pronounced  by  them  to  be  the  most  original  and  practically  useful  work  that  has  been 
issued  for  many  years. 

HILLES  (M.  w.), 

Formerly  Lecturer  on  Anatomy,  &c.,  at  Westminster  Hospital, 

THE  POCKET  ANATOMIST.  Being  a  Complete  Description  of 
the  Anatomy  of  the  Human  Body;  for  the  Use  of  Students.  Price,  in 
cloth,  $1.00;  in  Pocket-book  form  .  .  .  .  .  $1.25 

HEATH  (CHRISTOPHER),  F.R.C.S., 

Surgeon  to  University  College  Hospital,  &c. 

INJURIES  AND  DISEASES  OF  THE  JAWS._  The  Jacksonian 
Prize  Essay  of  the  Royal  College  of  Surgeons  of  England,  1867.  Sec- 
ond Edition,  Revised,  with  over  150  Illustrations.  Octavo.  Price, 

$5.00 

SAME  AUTHOR. 
A  MANUAL  OF  MINOR  SURGERY  AND  BANDAGING,  for 

the  Use  of  House  Surgeons,  Dressers,  and  Junior  Practitioners.     With 
a  Formulae  and  Numerous  Illustrations.      i6mo.       Price          .     $2.00 

HAYDEN  (THOMAS),  M.  D., 

Fellow  of  the  King  and  Queen's  College  of  Physicians,  &c,,  &c, 

THE  DISEASES  OF  THE  HEART  AND  AORTA.  With  81 
Illustrations.  In  two  volumes,  Octavo,  of  over  1200  pages.  Price,  *  6.00 

HUFELAND  (c.  w.),  M.D. 

THE  ART  OF  PROLONGING  LIFE.  Edited  by  ERASMUS  WIL- 
SON, M.  D.,  F.  R.S.,  &c.  121110.  Cloth *i.oo 

The  highly  practical  character  of  Dr.  Hufeland's  book,  the  sound  advice  which  it  con- 
tains, and  its  elevated  moral  tone,  recommend  it  for  extensive  circulation  both  among 
professional  and  non-professional  readers. 


20 
HEWSOK  (ADDINELL,)  M.  D. 

Attending  Surgeon  Pennsylvania  Hospital,  &c, 

EARTH  AS  A  TOPICAL  APPLICATION  IN  SURGERY. 
Being  a  full  Exposition  of  its  use  in  all  the  Cases  requiring  Topical 
Applications  admitted  in  the  Surgical  Wards  of  the  Pennsylvania  Hospi- 
tal during  a  period  of  Six  Months.  With  Illustrations.  Price  $2.50 


HUTCHINSON  (JONATHAN),  F.  R.  C.  S. 

Senior  Surgeon  to  the  London  Hospital, 

ILLUSTRATIONS  OF  CLINICAL  SURGERY.  Consisting  of 
Plates,  Photographs,  Wood-cuts,  Diagrams,  etc.,  Illustrating  Surgical 
Diseases,  Symptoms  and  Accidents,  also  Operations  and  other  Methods 
of  Treatment.  With  Descriptive  Letter-press.  7  Parts  now  ready. 
Each  Part  complete  in  itself.  Price,  per  Part  ....  $2.50 
rospectuses  furnished  upon  application. 


HODGE  (HUGH  L.),  M.  D. 

Emeritus  Professor  in  the  University  of  Pennsylvania. 

HODGE     ON      FCETICIDE,    OR     CRIMINAL     ABORTION. 

Fourth  Edition.     Price,  in  paper,  30  cents;  in  cloth,  .         .     .50 

HODGE'S  (H.  LENOX)  NOTE-BOOK  FOR  CASES  OF  OVARIAN 
TUMORS.  With  Diagrams,  etc.  Price,  ......  50 

HOLDEN  (EDGAR),  A.  M.,  M.  D., 

Of  Newark,  New  Jersey, 

CONTAINING  THREE  HUNDRED  ILLUSTRATIONS. 

THE  SPHYGMOGRAPH.  Its  Physiological  and  Pathological  In- 
dications. The  Essay  to  which  was  awarded  the  Stevens  Triennial 
Prize  in  the  College  of  Physicians  and  Surgeons  in  New  York,  April, 
1873.  Illustrated  by  Three  Hundred  Engravings  on  Wood.  One  vol- 
ume octavo.  Price  .........  *2.oo 

HOOD  (P.),  M.D. 

A  TREATISE  ON  GOUT,  RHEUMATISM,  AND  THE  ALLIED 
AFFECTIONS.  Crown  octavo.  .  .  .  $4.25 

HANCOCK  (HENRY),  F.R.C.S. 

ON  THE  OPERATIVE  SURGERY  OF  THE  FOOT  AND 
ANKLE.  Numerous  Illustrations.  Octavo.  .  .  .  $6.00 

JONES  (T.  WHARTON),  F.R.S. 

DEFECTS  OF  SIGHT  AND  HEARING.  Their  Nature,  Causes, 
Prevention,  &c.  Second  Edition.  Price  ...  -  *i.oo 

JONES,  SIEVEKING,  AND  PAYNE. 

A  MANUAL  OF  PATHOLOGICAL  ANATOMY.     By  C.  HAND- 

FIELD  JONES,  M.  D.,  F.  R.  S.,  Physician  to  St.  Mary's  Hospital;  and 
EDWARD  H.  SIEVEKING,  M.D.  ,  F.R.C.P.,  Physician  to  St.  Mary's  Hos- 
pital. A  New  and  Enlarged  Edition.  Edited  by  J.  F.  PAYNE,  M.B., 
F.  R.C.P..  Assistant  Phvsician  and  Lecturer  on  Morbid  Anatomv  at  St. 


21 
KIRBY  (E.  A.),  M.  D.,  M.  R.  C.  S.  Eng., 

Late  Physician  to  the  City  Dispensary, 

ON  THE  ADMINISTRATION  AND  VALUE  OF  PHOSPHO- 
RUS, as  a  Remedy  for  Loss  of  Nerve  Power,  Neuralgia,  Hysteria,  etc. 
With  Formulae  for  Combinations  with  Iron,  etc. 

LAWSON  (GEORGE),  F.R.C.S., 

Surgeon  to  the  Royal  London  Ophthalmic  Hospital, 

DISEASES  AND  INJURIES  OF  THE  EYE,  THEIR  MEDICAL 
AND  SURGICAL  TREATMENT.  Containing  a  Formulary,  Test 
Types,  and  Numerous  Illustrations.  Price  .  .  .  .  *  2.00 

This  Manual  is  admirably  clear  and  eminently  practical.  The  reader  feels  that  he  is  in 
the  hands  of  a  teacher  who  has  a  right  to  speak  with  authority,  and  who,  if  he  may  be  said 
to  be  positive,  is  so  from  the  fulness  of  knowledge  and  experience,  and  who,  while  well  ac- 
quainted with  the  writings  and  labors  of  other  authorities  on  the  matters  he  treats  of,  has 
himself  practically  worked  out  what  he  teaches.  —  London  Medical  Times  and  Gazette. 

LEBER  &  ROTTENSTEIN  (DRS.). 

DENTAL  CARIES  AND  ITS  CAUSES.  An  Investigation  into 
the  Influence  of  Fungi  in  the  destruction  of  the  Teeth,  translated  by 
THOMAS  H.  CHANDLER,  D.M.D  ,  Professor  of  Mechanical  Dentistry  in 
the  Dental  School  of  Harvard  University.  With  Illustrations.  Octavo. 
Price  .  .  .  .  .  .  .  .  •  .  .  *  1.25 

This  work  is  now  considered  the  best  and  most  elaborate  work  on  Dental  Caries.  It  is 
everywhere  quoted  and  relied  upon  as  authority  by  the  profession,  who  have  seen  it  in  the 
original,  and  by  authors  writing  on  the  subject. 

LEGG  (j.  WICKHAM),  M.D. 

Member  of  the  Royal  College  of  Physicians,  &c, 

A  GUIDE  TO  THE  EXAMINATION  OF  THE  URINE.     For 

the  Practitioner  and  Student.  Fourth  Edition.  i6mo.  Cloth!  Price,  $0.75 

Dr.  Legg's  little  manual  has  met  with  remarkable  success;  the  speedy  exhaustion  of  t\vo 
editions  has  enabled  the  author  to  make  certain  emendations  which  add  greatly  to  its  value. 
It  can  confidently  be  commended  to  the  student  as  a  safe  and  reliable  guide. 

LEARED  (ARTHUR),  M.D.,  F.R.C.P. 
IMPERFECT  DIGESTION:  ITS  CAUSES  AND  TREATMENT. 

The  Sixth  Edition,  Revised  and  Enlarged.       .         .         .         .     $1.75 

LESCHER  (F.  HARWOOD). 

THE  ELEMENTS  OF  PHARMACY.  For  Students.  The  Fourth 
Edition,  Revised  and  Enlarged.  Octavo $3-oo 

KOLLMEYER^T^.),  A.  M.,  M.  D. 

Professor  of  Materia  Medica  and  Therapeutics,  Montreal  College, 

CHEMIA  COARTATA  ;  or,  The  Key  to  Modern  Chemistry.  With 
Numerous  Tables,  Tests,  &c.,  &c.  Price,  ....  $2.25 


LIVEING  (EDWARD),  M.  D. 
ON    MEGRIM,    SICK-HEADACHE,    AND     SOME    ALLIED 


22 
LEWIN  (DR.  GEORGE). 

Professor  at  the  Fr,-Wilh,  University,  and  Surgeon-in-Chief  of  the  Syphilitic  Wards  and  Skin  Diseases  of 

the  Charity  Hospital,  Berlin, 

THE  TREATMENT  OF  SYPHILIS  by  Subcutaneous  Sublimate 
Injections.  With  a  Lithographic  Plate  illustrating  the  Mode  and  Proper 
Place  of  administering  the  Injections,  and  of  the  Syringe  used  for  the 
purpose.  Translated  by  CARL  PRCEGLER,  M.D.,  late  Surgeon  in  the 
Prussian  Service,  and  E.  H.  GALE,  M.D.,  late  Surgeon  in  the  United 

States  Army.     Price *i-5o 

The  great  number  of  cases  treated,  some  fourteen  hundred,  within  a  period  of  four  years, 
in  the  wards  of  the  Charity  Hospital,  Berlin,  only  twenty  of  which  were  returned  on 
account  of  Syphilitic  relapses,  certainly  entitles  the  method  of  treatment  advocated  by  this 
distinguished  syphilographer  to  the  attention  of  all  physicians  under  whose  notice  syphilitic 


cases  come. 


LIZARS  (JOHN),  M.  D. 

Late  Professor  of  Surgery  in  the  Royal  College  of  Surgeons,  Edinburgh, 

THE  USE   AND   ABUSE   OF   TOBACCO.      From   the   Eighth 
Edinburgh  Edition.      i2mo.     Price,  in  flexible  cloth,  .         *o.so 

This  little  work  contains  a  History  of  the  introduction  of  Tobacco,  its  general  characteris- 
tics ;  practical  observations  upon  its  effects  on  the  system ;  the  opinion  of  celebrated  profes- 
sional men  in  regard  to  it,  together  with  cases  illustrating  its  deleterious  influence,  &c.,  &c. 

MACNAMARA  (c.). 

Surgeon  to  the  Ophthalmic  Hospital,  and  Professor  of  Ophthalmic  Medicine  in  the  Medical  College,  Calcutta, 

MANUAL   OF  THE   DISEASES   OF  THE  EYE.     The      Third 
Edition,   carefully   Revised;  with  Additions,  and  numerous    Colored 
Plates,  Diagrams  of  the   Eye,  many  Illustrations  on  Wood,  Snellen's 
Test  Types,  &c.,  &c.     Price  .         .         .         .         .         .     *  4.00 

"  This  work  when  first  published  took  its  place  in  medical  literature  as  the  most  complete, 
condensed,  and  well-arranged  manual  on  ophthalmic  surgery  in  the  English  language. 
Arranged  especially  for  medical  students,  it  became,  however,  the  work  of  reference  for  the 
busy  practitioner,  who  could  obtain  nearly  all  that  was  best  worth  knowing  on  (his  subject, 
tersely  stated,  and  easily  found  by  the  aid  of  the  excellent  marginal  notes  on  the  contents 
of  the  paragraphs."  —  Philadelphia  Medical  Times. 

MACKENZIE  (MORELL),  M.  D. 

Physician  to  the  Hospital  for  Diseases  of  the  Throat,  London,  &c, 

GROWTHS  IN  THE  LARYNX.     Their  History,  Causes,  Symp- 
toms, Diagnosis,  Pathology,  Prognosis,  and  Treatment.     With  Reports 
and  Analysis  of  One  Hundred  Consecutive  Cases  treated  by  the  Author ; 
and  a  Tabular  Statement  of  every  published  case  treated  since  the  in- 
vention of  the    Laryngoscope.       With  numerous   Colored  and  other 
Illustrations.     Octavo.     Price         .         .         .         .         .         .     *  2.50 

Dr.  Mackenzie's  position  has  given  him  great  advantages  and  a  large  experience  in  the 

treatment  of  Diseases  of  the  Throat,  and  for  many  years  lie  has  been  regarded  as  a  leading 

authority  in  this  department  of  Surgery.    The  Illustrations  have  been  prepared  with  great 

care  and  expense. 

OTHER  WORKS  BY  SAME  AUTHOR. 

THE   LARYNGOSCOPE  IN  DISEASES    OF  THE   THROAT. 

With  an  Appendix  on  Rhinoscopy,  and  an  Essay  on  Hoarseness  and 
Loss  of  Voice.  With  Additions  by  J.  Sous  COHEN,  and  Numerous 
Illustrations  on  Wood  and  Stone.  Price  .... 

PHARMACOPCEIA  OF   THE    HOSPITAL   for   Diseases  of  the 
Throat;  with  One  Hundred  and  Fifty  Formulae  for  Gargles,  &c.,  &c. 

Price £1.25 

9 


23 

MEIGS  AND  PEPPER. 

A  PRACTICAL  TREATISE  ON  THE   DISEASES  OF  CHIL- 
DREN.    By  J.  FORSYTH  MEIGS,  M.D.,  Fellow  of  the  College  of  Physi- 
cians of  Philadelphia,  &c.,  &c.,  and  WILLIAM  PEPPER,  M.D.,  Physician 
to  the  Philadelphia  Hospital,  &c.     Sixth  Edition,  thoroughly  Revised 
and  greatly  Enlarged,  forming  a  Royal  Octavo  Volume  of  over  1000 
pages.     Price,  bound  in  cloth,  $6.00;  leather          .         .         .     $7.00 
It  is  the  most  complete  work  on  the  subject  in  our  language.     It  contains  at  once  the  re- 
sults of  personal,  and  the  experience  of  others.     Its  quotations  from  the  most  recent  author- 
ities, at  home  and  abroad,  are  ample,  and  we  think  the  authors  deserve  congratulations  for 
having  produced  a  book  unequalled  for  the  use  of  the  student  and  indispensable  as  a  work 
of  reference  for  the  practitioner.  —  American  Medical  Journal. 

MURPHY  (JOHN  G.),  M.D. 

A  REVIEW  OF  CHEMISTRY  FOR  STUDENTS.  Adapted  to 
the  Courses  as  Taught  in  the  Principal  Medical  Schools  in  the  United 
States.  .  $1.25 

MENDENHALL  (GEORGE),  M.D., 

Professor  of  Obstetrics  in  the  Medical  College  of  Ohio,  &c, 

MEDICAL  STUDENT'S  VADE  MECUM.  A  Compendium  of 
Anatomy,  Physiology,  Chemistry,  the  Practice  of  Medicine,  Surgery, 
Obstetrics,  Diseases  of  the  Skin,  Materia  Medica,  Pharmacy,  Poisons, 
&c.,  &c.  Eleventh  Edition,  Revised  and  Enlarged,  with  224  Illustra- 
tions. In  cloth  .........*  2.00 

MAXSON  (EDWIN  R.),  M.D., 

Formerly  Lecturer  on  the  Practice  of  Medicine  in  the  Geneva  Medical  College,  &.C, 

THE  PRACTICE  OF  MEDICINE.      .  .    *  3.00 

MARSH AlZ^HN),  F.R.S., 

Professor  of  Surgery,  University  College,  London, 

PHYSIOLOGICAL  DIAGRAMS.  Life-size,  and  Beautifully  Col- 
ored. An  Entirely  New  Edition,  Revised  and  Improved,  illustrating 
the  whole  Human  Body,  each  Map  printed  on  a  single  sheet  of  paper, 
seven  feet  long  and  three  feet  nine  inches  broad. 

No.  1.  The  Skeleton  and  Ligaments. 


No.  2.  The  Muscles,  Joints,  and  Animal  Me- 
chanics. 

No.  3.  The  Viscera  in  Position.  —  The  Struc- 
ture of  the  Lungs. 

No.  4.  The  Organs  of  Circulation. 

No.  5.  The  Lymphatics  or  Absorbents. 

No.  6.  The  Digestive  Organs. 


No.    7.  The  Brain  and  Nerves. 

No.    8.  The  Organs  of  the  Senses  and  Organs 

of  the  Voice.    Plate  1. 
No.    9.  The  Organs  of  the  Senses.    Plate  2. 
No.  10.  The    Microscopic    Structure  of  the 

Textures.     Plate  1. 
No.  11.  The    Microscopic    Structure  of  the 

Textures.    Plate  2. 


Price  of  the  Set,  Eleven  Maps,  in  Sheets,     .         .         .         .  $50.00 
"             "                   "                  "          handsomely  Mounted  on 

Canvas,  with  Rollers,  and  varnished,     .....  $80.00 

An  Explanatory  Key  to  the  Diagram.     Price         .          .         .         .  50 

MADDEN  (T.  M.),  M.  D. 

Author  of  "  Climatology  and  the  Use  of  Mineral  Waters," 

THE  HEALTH  RESORTS  OF  EUROPE  AND  AFRICA  for  the 
Treatment  of  Chronic  Diseases.  A  Hand -Book  the  result  of  the 
Author's  own  Observations  during  several  years  of  Health-Travel  in 
many  Lands,  containing,  also,  the  substance  of  the  Author's  former 
Work  on  CLIMATOLOGY  AND  THE  USE  OF  MINERAL  WATER?;. 


24 

MAUNDER  (c.  F.),  F.  R.  C.  S. 

Surgeon  to  the  London  Hospital)  formerly  Demonstrator  of  Anatomy  at  Guy's  Hospital. 

OPERATIVE  SURGERY.  Second  Edition,  with  One  Hundred 
and  Sixty-four  Engravings  on  Wood.  Price  .  .  .  $2.50 

BY  SAME  AUTHOR. 

SURGERY  OF  THE  ARTERIES,  including  Aneurisms,  Wounds, 
Haemorrhages,  Twenty-seven  Cases  of  Ligatures,  Antiseptic,  etc.  With 
1 8  Illustrations.  Price *  1.50 

MAYNE  (R.  G.),  M.  D.,  AND  MAYNE  (j.),  M.  D. 
MEDICAL  VOCABULARY:  An  Explanation  of  all  Names, 
Synonyms,  Terms,  and  Phrases  used  in  Medicine  and  the  Relative 
Branches  of  Medical  Science,  giving  their  correct  Derivation,  Meaning, 
Application,  and  Pronunciation.  Intended  especially  as  a  book  of 
reference  for  Physicians  and  Students.  Fourth  Edition,  Revised  and 
Enlarged.  Post  8vo.  450  pages.  Price  .  .  .  .  $3-oo 

MARTIN   (JOHNH.). 

Author  of  Microscopic  Objects,  &c, 

A  MANUAL  OF  MICROSCOPIC  MOUNTING.  With  Notes  on 
the  Collection  and  Examination  of  Objects,  and  upwards  of  One  Hun- 
dred Illustrations  on  Stone  and  Wood,  drawn  by  the  Author. 
Price $3-oo 

MEADOWS  (ALFRED),  M.  D. 

Physician  to  the  Hospital  for  Women,  and  to  the  General  Lying-in  Hospital,  &c, 

MANUAL  OF  MIDWIFERY.  A  New  Text-Book.  Including  the 
Signs  and  Symptoms  of  Pregnancy,  Obstetric  Operations,  Diseases  of 
the  Puerperal  State,  &c.,  &c.  Second  American  from  the  Third  Lon- 
don Edition.  Revised  and  Enlarged.  With  145  Illustrations.  *  3.00 

This  book  is  especially  valuable  to  the  Student  as  containing  in  a  condensed  form  a  large 
amount  of  valuable  information  on  the  subject  which  it  treats.  It  is  also  clear  and  methodi- 
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MILLER  (JAMES),  F.  R.  C.  S. 

Professor  of  Surgery  University  of  Edinburgh, 

ALCOHOL,  ITS  PLACE  AND  POWER.  From  the  Nineteenth 
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MILLER  AND  LIZARS. 

ALCOHOL:  Its  Place  and  Power.  By  JAMES  MILLER,  F.R.S.E.,  late 
Professor  of  Surgery  in  the  University  of  Edinburgh,  &c. — THE  USE 
AND  ABUSE  OF  TOBACCO.  By  JOHN  LIZARS,  late  Professor  to  the 
Royal  College  of  Surgeons,  &c.  The  Two  Essays  in  One  Volume. 
I2mo.  $1.00 


25 

MARSDEN   (ALEXANDER),  M.  D. 

A  NEW  AND  SUCCESSFUL  MODE  OF  TREATING  CERTAIN 
FORMS  OF  CANCER.  Second  Edition,  Colored  Plates.  .  $3.50 

MACDONALD  (j.  D.),  M.D., 

Deputy  Inspector-General  of  Hospitals,  Assistant  Professor  of  Hygiene,  Army  Medical  School,  &c, 

A  GUIDE  TO  THE  MICROSCOPICAL  EXAMINATION  OF 
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References,  Tables,  etc.,  etc.  Octavo.  Price  .  .  .  $3.00 

NORRIS  (GEORGE  w.),  M.  D., 

Late  Surgeon  to  the  Pennsylvania  Hospital,  &c, 

CONTRIBUTIONS  TO  PRACTICAL  SURGERY,  including 
numerous  Clinical  Histories,  Drawn  from  a  Hospital  Service  of  Thirty 
Years.  In  one  Volume,  Octavo.  Price  .  .  .  .  $4.00 

OVERMAN  (FREDERICK), 

Mining  Engineer,  &c. 

PRACTICAL    MINERALOGY,    ASSAYING    AND     MINING. 

With  a  Description  of  the  Useful  Minerals,  and  Instructions  for  Assay- 
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PHYSICIAN'S  VISITING  LIST,  PUBLISHED  ANNUALLY. 

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POWER,  HOLMES,  ANSTIE,  AND  BARNES. 
REPORTS  ON  THE  PROGRESS  OF  MEDICINE  AND  SUR- 
GERY, PHYSIOLOGY,  OPHTHALMIC  MEDICINE,  MID- 
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26 
PARKES  (EDWARD  A.),  M.  D., 

Professor  of  Military  Hygiene  in  the  Army  Medical  School,  &c, 

A  MANUAL  OF  PRACTICAL  HYGIENE.  The  Fourth  Revised 
and  Enlarged  Edition,  for  Medical  Officers  of  the  Army,  Civil  Medical 
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POWER  (HENRY),  M.  B.,  F.  R  .C.  S., 

Senior  Ophthalmic  Surgeon  to  St,  Bartholomew's  Hospital, 

THE  STUDENT'S  GUIDE  TO  THE  DISEASES  OF  THE  EYE. 

With  Engravings.     Preparing. 

PENNSYLVANIA  HOSPITAL  REPORTS. 

EDITED  BY  A  COMMITTEE  OF  THE  HOSPITAL  STAFF. 
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PAGET  (JAMES),  F.  R.  S., 

Surgeon  to  St,  Bartholomew's  Hospital,  &c, 

SURGICAL  PATHOLOGY.     Lectures  delivered  at  the  Royal  Col- 
lege of  Surgeons  of  England.     Third  London  Edition,  Edited   and 
Revised  by  WILLIAM  TURNER,   M.  D.     With  Numerous   Illustrations. 
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PEREIRA  (JONATHAN),  M.  D.,  F.  R.  S.,  &c. 
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27 
PARSONS  (CHARLES),  M.  D., 

Honorary  Surgeon  to  the  Dover  Convalescent  Homes,  &c,,  &c, 

SEA-AIR  AND  SEA-BATHING.  Their  Influence  on  Health  a 
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PARKER  (LANGSTON),  F.  R.  C.  S.  L. 

THE  MODERN  TREATMENT  OF   SYPHILITIC  DISEASES. 

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PRINCE  (DAVID),  M.  D. 

PLASTIC   AND   ORTHOPEDIC    SURGERY.     Containing   i.  A 

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Exposition  of  Plastic  Surgery.  With  numerous  Illustrations.  3.  Ortho- 
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PIESSE  (G.  w.  SEPTIMUS), 

Analytical  Chemist, 

WHOLE  ART  OF  PERFUMERY.  And  the  Methods  of  Obtaining 
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COPPER  MINING  AND  COPPER  ORE.  Containing  a  full  Descrip- 
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28 
RINDFLEISCH   (DR.  EDWARD). 

Professor  of  Pathological  Anatomy,  University  of  Bonn, 

TEXT-BOOK  OF  PATHOLOGICAL  HISTOLOGY.  An  Intro. 
duction  to  the  Study  of  Pathological  Anatomy.  Translated  from  the 
German,  by  WM.  C.  KLOMAN,  M.D.,  assisted  by  F.  T.  MILES,  M.D., 
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which  no  pathological  writer  or  student  can  afford  to  neglect,  who  desires  to  interpret  aright 
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man medical  literature.  What  makes  it  especially  valuable  is  the  fact  that  it  was  originated, 
as  its  author  hintself  tells  us,  more  at  the  microscope  than  at  the  writing-table.  Altogether 
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to  be  the  standard  book  of  the  kind." 

ROBERTS  (FREDERICK  T.).,  M.  D.,  B.  Sc. 

Assistant  Physician  and  Teacher  of  Clinical  Medicine  in  the  University  College  Hospital)  Assistant  Physician 
Brompton  Consumption  Hospital,  &c. 

A  HAND-BOOK   OF  THE  THEORY   AND   PRACTICE  OF 

MEDICINE.     Second  Edition,  Revised  and  Enlarged.     Cloth,  $5.00 

Leather,     6.00 

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and  in  one  volume,  such  information  with  regard  to  the  Principles  and  Practice  of 
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works  on  Practice  or  of  the  various  special  monographs. 


REYNOLDS  (j.  RUSSELL),  M.  D.,  F.  R.  S., 

Lecturer  on  the  Principles  and  Practice  of  Medicine,  University  College,  London, 

LECTURES   ON  THE  CLINICAL  USES  OF  ELECTRICITY. 

Delivered  at  University  College  Hospital.     Second  Edition,  Revised 
and  Enlarged.     Price     .         .         .         .         .         .         .         .    *  i.oo 


RYAN   (MICHAEL),  M.  D. 

Member  of  the  Royal  College  of  Physicians, 

PHILOSOPHY  OF  MARRIAGE,  in  its  Social,  Moral,  and  Physi- 
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it  in  the  latter.  It  is  intended  both  for  the  professional  and  general  reader. 

11 


29  x 

RADCLIFFE  (CHARLES  BLAND),  M.D., 

Fellow  of  the  Royal  College  of  Physicians  of  London,  &c. 

LECTURES  ON  EPILEPSY,  PAIN,  PARALYSIS,  and  other 
Disorders  of  the  Nervous  System.  With  Illustrations.  .  .  *  1.50 

The  reputation  which  Dr.  Badcliffe  possesses  as  a  very  able  authority  on  nervous  affections 
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throw  much  light  upon  the  Physiology  arid  Pathology  of  the  Nervous  System.  —  Canada 
Medical  Journal '. 

ROBERTSON  (A.),  M.D.,  D.D.S. 

A  MANUAL  ON  EXTRACTING  TEETH.  Founded  on  the 
Anatomy  of  the  Parts  involved  in  the  Operation,  the  kinds  and  proper 
construction  of  the  instruments  to  be  used,  the  accidents  likely  to  occur 
from  the  operation,  and  the  proper  remedies  to  retrieve  such  accidents. 
A  New  Revised  Edition 

The  author  is  well  known  as  a  contributor  to  the  literature  of  the  profession,  and  as  a 
clear,  terse,  and  practical  writer.  The  subject  is  one  to  which  he  has  devoted  considerable 
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to  the  dental  student  and  practitioner,  but  also  to  the  medical  student  and  surgeon.  —  Dental 
Cosmos. 

REESE  (JOHN;.),  M.D., 

Professor  of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania, 

AN  ANALYSIS  OF  PHYSIOLOGY.  Being  a  Condensed  View 
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Use  of  Students.  Second  Edition,  Enlarged.  .  .  .  $1.50 

SAME  AUTHOR. 

THE  AMERICAN  MEDICAL  FORMULARY.     Price      .    £1.50 
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RICHARDSON  (JOSEPH),  D.D.S. 

Late  Professor  of  Mechanical  Dentistry,  &c,,  &c, 

A  PRACTICAL  TREATISE  ON  MECHANICAL  DENTISTRY. 

Second  Edition,  much  Enlarged.     With  over  150  beautifully  executed 
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ROBERTS  (LLOYD  D.),  M.D., 

Vice- President  of  the  Obstetrical  Society  of  London,  Physician  to  St.  Mary's  Hospital,  Manchester. 

THE  STUDENT'S  GUIDE  TO  THE  PRACTICE  OF  MID- 
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RUTHERFORD  (WILLIAM),  M.  D.,  F.  R.  S.  E. 

Professor  of  the  Institutes  of  Medicine  in  the  University  of  Edinburgh, 

OUTLINES  OF  PRACTICAL  HISTOLOGY  FOR  STUDENTS 
AND  OTHERS.  Second  Edition,  Revised  and  Enlarged.  With  Illus- 
trations, &c.  Price $2.00 


30 

RIGBY  AND  MEADOWS. 

DR.  RIGBY'S  OBSTETRIC  MEMORANDA.  Fourth  Edition, 
Revised  and  Enlarged,  by  ALFRED  MEADOWS,  M.  D.,  Author  of  "A 
Manual  of  Midwifery,"  &c.  Price 50 

ROYLE'S  MANUAL  OF  MATERIA  MEDICA  AND  THERA- 
PEUTICS. The  Sixth  Revised  and  Enlarged  Edition.  Containing 
all  the  New  Preparations  according  to  the  New  British,  American, 
French,  and  German  Pharmacopoeias,  the  New  Chemical  Nomencla- 
ture, etc.,  etc.  Edited  by  JOHN  HARLEY,  M.  D..  F.  R.  C.  P.,  Assistant 
Physician  and  Lecturer  on  Physiology  at  St.  Thomas's  Hospital.  With 
139  Illustrations,  many  of  them  new.  One  vol.,  Demy  Octavo.  *  5.00 

RUPPANER  (ANTOINE),  M.  D. 

THE  PRINCIPLES  AND  PRACTICE  OF  LARYNGOSCOPY 
AND  RHINOSCOPY  IN  DISEASE?  OF  THE  THROAT,  &c. 
Fifty-nine  Illustrations.  Price  .  .  .  .  .  .  $1.50 

SANDERSON,  KLEIN,  FOSTER,  AND  BRUNTON. 

A  HAND-BOOK  FOR  THE  PHYSIOLOGICAL  LABORATORY. 

Being  Practical  Exercises  for  Students  in  Physiology  and  Histology,  by 

E.  KLEIN,  M.  D.,  Assistant  Professor  in  the  Pathological  Laboratory 
of   the   Brown   Institution,  London;    J.    BURDON-SANDERSON,  M.  D., 

F.  R.  S.,   Professor  of  Practical  Theology  in  University  College,  Lon- 
don; MICHAEL  FOSTER,  M.D.,  F.R.S.,  Fellow  of  and  Praelector  of  Phys- 
iology in  Trinity  College,  Cambridge;  and  T.  LAUDER BRUNTON,  M.D.., 
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trations  consist    of    One    Hundred    and    Twenty-three    octavo  pages, 
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SIEVEKING  (E.  H.),  M.D.,  F.R.C.S. 
THE  MEDICAL  ADVISER  IN  LIFE  ASSURANCE.    Price  $2.25 

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contingencies  upon  which  life  insurance  rests. 

SWAIN  (WILLIAM  PAUL),  F.R.C.S., 

Surgeon  to  the  Royal  Albert  Hospital,  Devonport, 

SURGICAL  EMERGENCIES:  A  MANUAL  CONTAINING 
CONCISE  DESCRIPTIONS  OF  VARIOUS  ACCIDENTS  AND 
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31     > 
STILLE  (ALFRED),  M.  D. 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  University  of  Pennsylvania,  &c, 

EPIDEMIC  MENINGITIS ;  or,  Cerebro-Spinal  Meningitis.  In  one 
volume,  Octavo.  .  .  .  .  .  .  .  .  $2.00 

This  monograph  is  a  timely  publication,  comprehensive  in  its  scope,  and  presenting  within 
a  small  compass  a  fair  digest  of  our  existing  knowledge  of  the  disease,  particularly  accept- 
able at  the  present  time.  It  is  just  such  a  one  as  is  needed,  and  may  be  taken  as  a  model 
for  similar  works. —  American  Journal  Medical  Sciences. 

SMITH  (WILLIAM  ROBERT), 

Resident  Surgeon,  Hants  County  Hospital, 

LECTURES  ON  THE  EFFICIENT  TRAINING  OF  NURSES 
FOR  HOSPITAL  AND  PRIVATE  WORK.  With  Illustrations. 
121110.  Cloth.  Price $2.25 

SMITH  (HEYWOOD),  M.  D., 

Physician  to  the  Hospital  for  Women,  &c. 

PRACTICAL  GYNAECOLOGY.  A  Hand-Book  for  Students  and 
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This  work  will  form  one  volume  of  the  Students1  Guide  Series,  or  Hand-Books  for  Prac- 
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SANSOM  (ARTHUR  ERNEST),  M.B., 

Physician  to  King's  College  Hospital,  &c, 

CHLOROFORM.     Its  Action  and  Administration.     Price         *  1.50 

BY  SAME  AUTHOR. 

LECTURES  ON  THE  PHYSICAL  DIAGNOSIS  OF  DISEASES 
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SCANZONI  (F.  w.  VON), 

Professor  in  the  University  of  Wurzburg. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  .OF  THE 
SEXUAL  ORGANS  OF  WOMEN.  Translated  from  the  French. 
By  A.  K.  GARDNER,  M.D.  With  Illustrations.  Octavo.  .  $5.00 

STOKES  (WILLIAM), 

Regius  Professor  of  Physic  in  the  University  of  Dublin, 

THE  DISEASES  OF  THE  HEART  AND  THE  AORTA. 
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32 
SWERINGEN   (HIRAM   v.). 

Member  American  Pharmaceutical  Association,  &Ci 

PHARMACEUTICAL  LEXICON.  A  Dictionary  of  Pharmaceu- 
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and  terms  of  Pharmacy,  with  appropriate  selections  from  the  collateral 
sciences.  Formulae  for  officinal,  empirical,  and  dietetic  preparations; 
selections  from  the  prescriptions  of  the  most  eminent  physicians  of 
Europe  and  America;  an  alphabetical  list  of  diseases  and  their  defini- 
tions; an  account  of  the  various  modes  in  use  for  the  preservation  of 
dead  bodies  for  interment  or  dissection ;  tables  of  signs  and  abbrevia- 
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Designed  as  a  guide  for  the  Pharmaceutist,  Druggist,  Physician,  &c. 

Royal  Octavo.     Price  in  cloth *3-oo 

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SEWILL  (H.  E.),  IVLlTc.  S.,  Eng-.,  L.  D.  S., 

Dental  Surgeon  to  the  West  London  Hospital, 

THE  STUDENT'S  GUIDE  TO  DENTAL  ANATOMY  AND 
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SHEPPARD  (EDGAR),  M.  D. 

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MADNESS,  IN  ITS  MEDICAL,  SOCIAL,  AND  LEGAL  AS- 
PECTS. A  series  of  Lectures  delivered  at  King's  College,  London. 
Octavo.  Price $2.50 

SAVAGE  (HENRY),  M.  D.,  F.  R.  C.  S. 

Consulting  Physician  to  the  Samaritan  Free  Hospital,  London, 

THE  SURGERY,  SURGICAL  PATHOLOGY,  and  Surgical  Anat- 
omy of  the  Female  Pelvic  Organs,  in  a  Series  of  Colored  Plates 
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SAME  AUTHOR. 

AN  EXPOSITION  OF  THE  NATURE  OF  THE  SURGICAL 
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SUTTON  (FRANCIS),  F.  C.  S. 

A  SYSTEMATIC  HAND-BOOK  OF  VOLUMETRIC  ANALYSIS, 

or  the  Quantitative  Estimation  of  Chemical  Substances  by  Measure, 
Applied  to  Liquids,  Solids,  and  Gases.  Third  Edition,  enlarged. 
With  numerous  Illustrations.  Now  Ready.  Price  .  .  $5-5° 

SMITH  (EUSTACE),  M.D. 

Physician  to  the  East  London  Hospital  for  Diseases  of  Children,  &c. 

CLINICAL  STUDIES  OF  DISEASES  OF  THE  LUNGS  IN 
CHILDREN.  Price $2.50 


33 

TANNER  (THOMAS  HAWKES),  M.D.,  F.R.C.P.,  &c. 

THE  PRACTICE  OF  MEDICINE.     Sixth  American  from  the  last 
London  Edition.     Revised,  much  Enlarged,  and  thoroughly  brought  up 
to  the  present  time.     With  a  complete  Section  on  the  Diseases  Peculiar 
to  Women,  an  extensive  Appendix  of  Formulae  for  Medicines,  Baths, 
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aims  at  teaching  how  to  recognize  and  how  to  cure  disease,  and  in  this  he  is  thoroughly  suc- 
cessful. ...  It  is,  indeed,  a  wonderful  mine  of  knowledge.  —  Medical  Times. 

SAME  AUTHOR. 

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A. MEMORANDA  OF  POISONS.  A  New  and  much  Enlarged 
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TYSON  (JAMES),  M.D., 

Lecturer  on  Microscopy  in  the  University  of  Pennsylvania,  &c, 

THE  CELL  DOCTRINE.  Its  History  and  Present  State,  with  a 
Copious  Bibliography  of  the  Subject,  for  the  use  of  Students  of  Medi- 
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For  the  use  of  Physicians    and    Students.     With   a    Colored  Plate   and 
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TAFT  (JONATHAN),  D.D.S., 

Professor  of  Operative  Dentistry  in  the  Ohio  College,  &c, 

A  PRACTICAL  TREATISE  ON  OPERATIVE  DENTISTRY. 

Third  Edition,  thoroughly  Revised,  with  Additions,  and  fully  brought 
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tions.    Octavo.     Price,  in  cloth,  $4.25.     In  leather,       .         .     $5.00 
Professor  Tafr  has  done  good  service  in  thus  embodying,  in  a  separate  volume,  a  compre- 
hensive view  of  operative  dentistry.     This  gentleman's  position  as  a  teacher  must  have  ren- 
dered him  familiar  with  the  most  recent  views  which  are  entertained  in  America  on  this 
matter,  while  his  extensive  experience  and  well-earned  reputation  in  practice  must  have 
rendered  him  a  competent  judge  of  their  merits.     We  willingly  commend  Professor  Taft's 
able  and  useful  work  to  the  profession. —  London  Dental  Review. 

3 


34 
TROUSSEAU  (A.), 

Professor  of  Clinical  Medicine  to  the  Faculty  of  Medicine,  Paris,  &c, 

LECTURES  ON  CLINICAL  MEDICINE.     Delivered  at  the  HStel 
Dieu,  Paris.     Translated  from  the  Third  Revised  and  Enlarged  Edition 
by  P.  VICTOR  BAZIRE,  M.D.,  London  and  Paris;  and  JOHN  ROSE  COR- 
MACK,  M.D.,  Edinburgh,  F.R.S.,  &c.     With  a  full  Index,  Table  of  Con- 
tents, &c.      Complete  in  Two  volumes,  royal  octavo,  bound  in  cloth. 
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the  profession,  the  publishers  now  issue  this  edition,  containing  all  the  lectures  as  contained 
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TILT  (EDWARD  JOHN),  M.D. 

THE  CHANGE  OF  LIFE  IN  HEALTH  AND  DISEASE.  A 
Practical  Treatise  on  the  Nervous  and  other  Affections  incidental  to 
Women  at  the  Decline  of  Life.  From  the  Third  London  Edition. 

Price $3-oo 

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TOYNBEE  (j.),  F.R.S. 

ON  DISEASES  OF  THE  EAR.  Their  Nature,  Diagnosis,  and 
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THOMPSON  (SIR  HENRY),  F.R.C.S.,  &c. 

ON  THE  PREVENTIVE  TREATMENT  OF  CALCULOUS 
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THORNTON  (w.  PUGIN),  M.D. 

Surgeon  to  Hospital  for  Diseases  of  the  Throat,  &c, 

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THOROWGOOD7joHN  c.),  M.D., 

Lecturer  on  Materia  Medicaatthe  Middlesex  Hospital, 

THE  STUDENT'S  GUIDE  TO  MATERIA  MEDICA.  With 
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TYLER  SMITH  (w.),  M.D., 

Physician,  Accoucheur,  and  Lecturer  on  Midwifery,  &.Ci 

ON    OBSTETRICS.     A    Course    of    Lectures.     Edited   bv  A.  K. 


35 
THOROWGOOD  (j.  c.),  M.  D. 

Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest,  and  to  the  West  London  Hospital,  &c, 
NOTES    ON   ASTHMA.       Its   various    Forms,   their    Nature   and 
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Second  Edition.     Price          .         .         .         .         .         .         .     *  1.50 

TOMES  (JOHN),  F.  R.  S. 

Late  Dental  Surgeon  to  the  Middlesex  and  Dental  Hospitals,  &c, 

A  SYSTEM  OF  DENTAL  SURGERY.  The  Second  Revised  and 
Enlarged  Edition,  by  CHARLES  S.  TOMES,  M.A.,  Lecturer  on  Dental 
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Lecturer  on  Anatomy  and  Physiology,  and  Assistant  Surgeon  to  the  Dental  Hospital  of  London, 

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TRANSACTIONS  OF  THE  COLLEGE  OF  PHYSICIANS 

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THUDICHUM  (JOHN  L.  w.),  M.  D., 

Lettsomian  Professor  of  Medicine,  Medical  Society,  London,  &c, 

ON  PATHOLOGY  OF  THE  URINE.  Including  a  Complete 
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TOLAND  (H.  H.),  M.  D., 

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the  University  of  California, 

LECTURES  ON  PRACTICAL  SURGERY.  With  Numerous 
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TIBBITS  (HERBERT),  M.  D. 

Medical  Superintendent  of  the  National  Hospital  for  the  Paraly2ed  and  Epileptic,  &c, 

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other  medir.al  instriimpiits. 


36 

VIRCHOW  (RUDOLPHE),  Professor,  Universitf  of  Berlin, 
CELLULAR  PATHOLOGY.     144  Illustrations.     Octavo.      $5.00 

BY  SAME  AUTHOR. 

POST-MORTEM  EXAMINATIONS.  A  Description  and  Expla- 
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A  PRIMER  OF  CHEMISTRY.  Including  Analysis.  i8mo. 
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WARING  (EDWARD  JOHN),  F.R.C.S.,  F.L.S.,  &c.,  &c. 

PRACTICAL  THERAPEUTICS.  Considered  chiefly  with  refer- 
ence to  Articles  of  the  Materia  Medica.  Third  American  from  the  last 
London  Edition.  Price,  in  cloth,  *  4.00;  leather  .  .  ^5.00 

There  are  many  features  in  Dr.  Waring's  Therapeutics  which  render  it  especially  valuable 
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THE  PHYSICIAN'S  POCKET,  DOSE," AND  SYMPTOM  BOOK. 

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37 
WILSON  (GEORGE),  M.  A.,  M.  D. 

Medical  Officer  to  the  Convict  Prison  at  Portsmouth, 

A  HANDBOOK  OF  HYGIENE  AND   SANITARY  SCIENCE. 

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THE  STUDENT'S  GUIDE  TO  HUMAN  OSTEOLOGY.     With 

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WARD  (STEPHEN  H.),  M.D.,  F.  R.  C.  P. 

Physician  to  the  Seaman's  Hospital,  &c,,  &c, 

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CONTAINING  THREE  HUNDRED  AND  SEVENTY-ONE  ILLUSTRATIONS. 

THE  ANATOMIST'S  VADE  MECUM.  A  Complete  System  of 
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Professor  of  Histology,  &c,,  In  the  University  of  Vienna, 

PENTAL   PATHOLOGY.      The  Pathology  of  the  Teeth.     With 

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Edition,  translated  by  W.  E.  BOARDMAN,  M.D.,  with  Notes  by  THOS. 
B.  HITCHCOCK,  M.D.,  Professor  of  Dental  Pathology  and  Therapeutics 
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